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AN     INDEX    OF    PROGNOSIS 

AND    END-RESULTS    OF    TREATMENT 


AN 


INDEX  OF  PROGNOSIS 

AND  END-RESULTS  OF  TREATMENT 


BY 

VARIOUS    WRITERS 


A.  RENDLE   SHORT,  M.D.,  B.S.,  B.Sc.  (Lond.),  F.R.C.S.  (Eng. 

CAPTAIN    R.A.M.C, 

Hunterian  Professor,    Royal  College   of  Surgeons;    Exaininer  in   Physiology   for   the   F.R.C.S^ 
Hon.  Assistant  Surgeoti,  Bristol  Royal  Infirmary ;    Lecttirer  on  Physiology, 
University   of  Bristol. 


NEW     YORK 

WILLIAM     WOOD     AND     COMPANY 
MDCCCCXV 


PRINTED   IK 
GREAT   BRITAIN 


/ 


KC\00 


PREFACE 

This  volume  is  issued  as  a  companion  to  the  Index  of  Treatment  and 
Index  of  Differential  Diagnosis  brought  out  by  the  same  pubHshers. 
Its  principal  aims  are  : 

(i)  To  set  forth  the  results,  and  particularly  the  end-results,  of 
various  methods  of  treatment,  in  such  a  form  as  will  enable  the 
practitioner  to  obtain  a  fair,  unbiassed,  reasoned  opinion  as  to  the 
prospects  of  securing  for  his  patient  permanent  relief,  and  the  risks 
of  such  treatment. 

(2)  To  furnish  data  by  means  of  which,  apart  from  the  question 
of  treatment,  one  may  seek  to  arrive  at  an  accurate  forecast  of 
what  will  probably  happen  to  the  individual  patient. 

Although  the  art  of  prognosis  is  vitally  important — and  nearly 
every  intelhgent  patient,  or  his  friends,  will  ask  for  an  opinion  as  to 
his  prospects,  and  will  judge  of  the  capacity  of  the  medical  attendant 
by  the  accuracy  of  that  opinion— it  is  extraordinary  to  find  how  little 
help  is  given  by  current  text-books.  Especially  is  it  difficult  to  find 
rehable  data  as  to  the  end-results  of  treatment,  more  particularly 
surgical  treatment.  Even  large  monographs  on  special  diseases, 
though  they  usually  advise  certain  measures,  only  express  a  pious 
opinion  as  to  the  probable  results  thereof,  unsupported  by  any 
trustworthy  figures. 

The  compilation  of  the  present  Index  has,  therefore,  been  extremely 
laborious,  because  a  painstaking  search  through  the  wilderness  of 
modern  medical  literature  in  several  languages  has  often  yielded 
very  small  results.  The  editor  has  found  it  necessary  to  supplement 
the  published  records  by  investigating  the  end-results  of  treatment 
at  the  Bristol  Royal  Infirmary — upwards  of  a  thousand  patients 
having  been  communicated  with  for  this  purpose  ;  and  other  con- 
tributors have  also  taken  great  trouble  to  acquire,  from  their  private 
or  hospital  practice,  the  necessary  figures. 

The  only  way  to  express  end-results  in  such  a  manner  as  to  give 
authoritative  guidance  is  by  quoting  statistics.  Thus  alone  can  the 
practitioner,  unless  his  personal  experience  is  far  wider  than  ordinary, 
verify  or  quahfy  the  promises  of  an  enthusiastic  specialist. 


vi  PREFACE 

Published  end-results  have  been  calculated  on  various  systems, 
and  may  be  hopelessly  unreliable.  Sometimes,  for  instance,  the 
cases  are  too  few  to  warrant  generaUzation.  Very  many  figures  are 
vitiated  by  too  early  reporting  ;  patients  with  cancer,  for  example, 
having  been  followed  up  for  a  year  or  two  only. 

There  are  three  principal  classes  of  statistics  :  (i)  Reports  culled 
from  the  literature  ;  (2)  The  records  of  individual  surgeons  ;  and  (3) 
Studies  of  hospital  cases  published  by  registrars  or  others.  Pickings 
from  the  hterature  are  often  absolutely  misleading,  because  successes 
and  curiosities  have  been  selected  for  publication,  while  failures  are 
unmentioned.  The  records  of  individual  surgeons  are  sometimes 
touched  with  couleur  de  rose.  Hospital  figures  are  the  most  reUable, 
but  are  usually  less  favourable  than  the  results  obtained  in  private 
practice,  where  patients  are  naturally  better  able  to  look  after  them- 
selves. 

Throughout  this  book,  therefore,  careful  note  is  taken  of  the  source 
of  the  information,  and  its  relative  value  is  taken  into  account  in  the 
summing  up.  We  believe,  moreover,  it  will  be  found  that  the  figures 
are  so  presented  that  they  do  not  unduly  obtrude  themselves,  or 
confuse  the  plain  and  simple  conclusions  of  the  text  which  accom- 
panies them. 

Lastly,  this  volume  is  unique  ;  nothing  of  similar  character  has 
appeared  before  or  can  compare  with  it.  It,  therefore,  possesses  a 
value  entirely  its  own,  and  one  which  time  will  not  diminish.  Should 
it  find  sufficient  favour  with  practitioners  for  further  editions  to  be 
called  for  in  the  decades  to  come,  the  present  compilation  will  yet 
maintain  its  position  as  a  register  of  the  progress  of  the  heahng  art 
up  to  the  time  of  its  appearance — a  date  memorable  in  the  world's 
history  as  that  of  the  Great  War. 

It  will  be  for  the  future  to  improve  upon  the  end-results   of 

treatment  here  recorded,  which  at  the  time  of  writing  have  attained 

"  thus  far,  but  no  farther." 

A.  RENDLE  SHORT. 

{Editor.) 

June,  1915. 


LIST    OF 
CONTRIBUTORS    AND    THEIR    SUBJECTS 

W.  Cecil  Bosanquet,  m.a.,  m.d.,  f.r.c.p.  ;  Physician  to  Consumption  Hospital, 
Brompton,  and  Charing  Cross  Hospital.  Diabetes. 

Francis  D.  Boyd,  c.m.g.,  m.d.,  cm.,  f.r.c.p.  ;  Physician  to  Royal  Infirmary, 
Edinburgh.  Medical  Diseases  of  Kidney. 

Dudley  W.  Buxton,  m.d.,  b.s.,  m.r.c.p.  ;  Anaesthetist  to  University  College 
Hospital  and  Royal  Dental  Hospital.  AncBsthetics. 

J.  Roger  Charles,  m.a.,  m.d.,  b.c,  f.r.c.p.  ;  Physician  to  the  Royal  Infirmary, 
Bristol.  Medical  G astro-intestinal  Diseases,  Influenza, 

Acidosis,  Gout,  Drug  Habits. 

Sir  Thomas  S.  Clouston  (the  late),  m.d.,  ll.d.,  f.r.c.p.  ;  Ex-President  of 
Royal  College  of  Physicians,  Edinburgh  ;  Physician  Superintendent,  Royal 
Asylum,   Edinburgh.  Mental  Diseases . 

Carey  F.  Coombs,  m.d.,  b.s.,  m.r.c.p.  ;  Assistant  Physician,  Bristol  General 
Hospital.  Diseases  of  Heart  and  Arteries. 

C.  W.  Daniels,  m.b.,  f.r.c.p.  ;  Physician  to  the  Albert  Dock  Hospital,  late 
Director  of  London  School  of  Tropical  Medicine.  Tropical  Diseases. 

Bryden  Glendining,  m.b.,  M.S.,  F.R.c.s.  ;  Obstetric  and  Gynaecological  Tutor, 
Middlesex  Hospital ;  Gynaecologist  to  Hampstead  and  N.W.  London 
Hospital.  GyncBcology  and  Obstetrics. 

A.    GooDALL,    M.D.,    F.R.C.P.  ;     Assistant    Physician   to   the    Royal   Infirmary, 

Edinburgh  ;    and 
G.  L.  GuLLAND,  M.A.,  B.sc,  M.D.,  F.R.C.P.  ;    Physician  to  the  Royal  Infirmary, 

Edinburgh.  Diseases  oj  the  Blood. 

E.  W.  GooDALL,  M.D.,  B.S.  ;  Mcdical  Superintendent,  Eastern  Hospital, 
Homerton.  Infective  Fevers. 

W.  J.  Greer,  f.r.s.c.i.  ;    Surgeon  to  the  Royal  Gwent  Hospital,  Newport. 

Fractures. 
W.  Sampson  Handley,  m.d.,  m.s.,  f.r.c.s.  ;    Surgeon  to  Out-patients,  Middlesex 
Hospital  ;    late  Surgeon  to  Bolingbroke  Hospital. 

Cancer  of  Breast  and  Rectum,  Melanotic  Sarcoma. 

J.  Ernest  Lane,  f.r.c.s.  ;  Senior  Surgeon  to  St.  Mary's  Hospital  and  London 
Lock  Hospital.  Syphilis  and  Gonorrhaa. 

A.  Latham,  m.a.,   m.d.,  f.r.c.p.  ;    Physician  to  St.   George's  Hospital,   Mount 

Vernon    Hospital,    and    Senior   Assistant   Physician,    Brompton   Hospital. 

Pulmonary  Tuberculosis,  Diseases  of  Lungs  and  Pleura. 


COXTRIBUTORS 


Hugh  Lett,  m.b.,  ch.B.,  f.r.c.s.  ;   Surgeon  to  the  London  Hospital.    Appendicitis. 

F.  J.  PoYNTON,  M.D.,  F.R.c.p.  ;  Senior  Phj-sician  to  Out-patients  to  University 
College  Hospital  and  Great  Ormond  Street  Hospital.       Rheumatic  Diseases. 

H.  D.  RoLLESTOX,  M.A.,  M.D.,  B.C.,  F.R.C.P.  ;  Senior  Physician  to  St.  George's 
Hospital ;    Physician  to  Victoria  Hospital  for  Children. 

Diseases  of  Liver,  Addison's  Disease,  Lymphadenotna. 

J.  H.  Seoueira,  M.D.,  F.R.C.P.,  F.R.C.S.  ;  Physician  to  Skin  Dept.,  London 
Hospital.  Skin  Diseases. 

James  Sherrex,  f.r.c.s.  ;  Surgeon  to  the  London  Hospital,  and  Senior  Surgeon 
Poplar  Hospital.  Surgical  Diseases  of  Stomach,  Nerve  Injuries. 

A.  Eendle  Short,  m.d.,  b.s.,  b.sc,  f.r.c.s.  ;  Assistant  Surgeon,  Bristol  Royal 
Infirmary.  General  Surgery. 

PuRVES  Stewart,  m.a.,  m.d.,  cm.,  f.r.c.p.  ;  Physician  to  the  Westminster 
Hospital  and  to  West  End  Hospital  for  Xervous_Diseases. 

Nervous  Diseases. 

J.  W.  Thomson  Walker,  m.b.,  cm.,  f.r.c.s.  ;  Surgeon  to  the  X.W.  London 
and  Hampstead  Hospital,  and  Assistant  Surgeon  to  St.  Peter's  Hospital 
for  Stone.  Surgical  Diseases  of  Bladder  and  Kidney. 

A.  J.  M.  Wright,  m.b.,  b.s.,  f.r.c.s.  ;  Surgeon  to  the  Nose  and  Throat  Dept., 
Bristol  General  Hospital.  Diseases  of  Nose  and  Throat. 


AN    INDEX    OF    PROGNOSIS 

And    End- Results    of    Treatment 


ABDOMINAL  INJURIES. — We  have  to  consider  the  consequence  of  (i)  Blows 
on  the  abdomen  ;  (2)  Punctured  wounds  ;  and  (3)  Gunshot  wounds.  It  will  be 
necessary  to  set  these  forth  according  to  the  viscera  which  may  be  injured. 

I.  Contusions. — After  a  severe  blow  on  the  abdomen,  the  patient  is  usually 
seen  within  a  few  hours  by  a  medical  man,  and  the  diagnosis  and  prognosis 
at  first  are  often  very  difficult.  Such  injuries  as  a  kick  by  a  horse,  buffer  acci- 
dents, and  cases  where  a  vehicle  has  run  over  the  abdomen,  are  always  to  be 
regarded  as  entailing  very  serious  possibilities,  because  great  force  may  have 
been  localized  upon  a  small  area.  It  is  extremely  important  to  realize  that 
the  degree  of  shock  when  the  patient  is  first  seen  is  most  misleading  as  a  guide 
to  diagnosis  or  prognosis.  Thus,  on  the  one  hand,  to  take  an  extreme  case,  a 
powerful  athlete  may  die  outright  as  a  result  of  a  blow  over  the  solar  plexus, 
without  any  laceration  of  abdominal  viscera  whatever.  An  area  the  size  of  a 
half  crown  is  well  known  to  pugilists  as  the  '  mark,'  where  a  hard  punch  will 
induce  instantaneous  shock.  If  the  injured  person  does  not  die  at  once,  however, 
he  will  almost  certainly  recover  completely,  provided  that  the  contusion  of  the 
abdomen  has  not  ruptured  any  important  viscera  or  vessels. 

On  the  other  hand,  the  prevalent  impression  that  after  rupture  of  one  of  the 
important  organs  the  patient's  pulse  will  necessarily  be  quick  and  feeble,  is 
misleading  to  the  last  degree,  and  many  reputations  have  suffered  because  the 
doctor  has  seen  a  patient  soon  after  the  injury,  and,  trusting  to  the  normal  pulse 
and  absence  of  shock,  has  sent  him  home  with  a  good  prognosis,  whereas  six 
hours  later  he  was  dying  of  internal  haemorrhage.  Most  hospitals  have  tragic 
stories  to  tell  of  this  calamity.  Ruptured  spleen  is  particularly  apt  to  lie  hidden 
in  this  way.  In  a  series  of  13  cases  of  rupture  of  various  abdominal  viscera 
.studied  by  the  writer,  in  only  3  was  the  pulse  over  100  when  first  seen,  and  these 
three  all  died  within  twenty-four  hours. 

It  ought  to  be  well  recognized  that  prognosis  is  absolutely  impossible  within  a 
few  hours  of  a  severe  injury  of  the  abdomen,  unless,  of  course,  the  patient  is 
already  obviously  dying.  Even  if  there  are  no  symptoms  whatever,  he  ought  to 
be  put  to  bed  and  carefully  watched,  the  pulse  being  counted  every  fifteen 
minutes  for  several  hours.  It  is  usually  possible  to  recognize,  when  he  is 
warm  in  bed,  and  given  hot  applications  for  the  abdomen,  that  the  condition 
remains  or  becomes  favourable  if  no  viscera  are  torn.  Morphia  ought  not  to  be 
given  until  the  diagnosis  is  certain,  as  it  masks  symptoms. 

On  the  other  hand,  if  important  organs  are  torn,  the  condition  will  get  worse, 
or  at  any  rate  there  will  be  no  improvement.  The  pulse-rate  often  rises  and  its 
volume  diminishes,  the  face  becomes  an.-cious,  the  patient,  as  we  say,  '  looks 
bad,'  and  there  is  often  rigidity  of  the  abdominal  wall.  The  temperature  mav 
be  subnormal.  Vomiting  is  fairly  common,  but  not  necessarily  important ;  even 
slight  haematemesis  may  be  of  no  serious  import.  In  a  case  under  the  writer's 
care,  in  spite  of  twice  vomiting  blood,  a  boy  recovered  without  further  trouble. 

I 


INDEX    OF    PROGNOSIS 


Evidence  of  free  fluid  in  the  abdomen,  or  the  pallor  and  air  hunger  of  great 
haemorrhage,  are,  of  course,  very  grave  signs.  In  ruptured  spleen  there  may  be 
fixed  dullness  in  the  left  flank  and  shifting  dullness  in  the  right.  Loss  of  liver 
dullness  is  of  no  importance. 

Such  signs  as  the  above  are  usually  to  be  detected  after  watching  the  patient 
for  four  or  five  hours,  and  may,  of  course,  be  evident  much  sooner.  They  urgently 
demand  laparotomy.  In  our  experience  at  the  Bristol  Royal  Infirmary,  mistakes 
in  diagnosis  in  cases  thus  watched  are  very  uncommon,  though  it  is  often  impos- 
sible to  tell  what  organ  is  damaged. 

One  possible  result  of  a  blow  on  the  abdomen  well  deserves  notice.  The  writer 
has  seen  two  cases  illustrating  it.  After  a  contusion  of  the  right  iliac  fossa,  acute 
appendicitis  may  come  on  rapidly.  In  the  first  case,  following  a  blow  by  a  foot- 
ball, there  was  pain,  tenderness,  and  rigidity,  but  the  patient  looked  well,  the 
pulse  was  normal,  and  he  walked  up  to  the  hospital.  The  local  signs  were 
attributed  to  the  blow  the  day  before,  and  the  lad  was  told  to  rest  at  home. 
Two  days  later  he  was  admitted  with  appendicitis  and  general  peritonitis,  and 
died.  In  the  second  case,  the  condition  when  first  seen  was  exactly  similar,  but 
the  temperature  was  taken,  and  found  to  be  raised.  This  boy  was  operated  on, 
and  recovered  well.     The  temperature  is  the  clue  to  these  very  deceiving  cases. 

Ruptured  Intestine. — We  are  greatly  indebted  to  the  careful  study  of  Berry 
and  Giuseppe  on  132  cases,  being  the  total  number  treated  in  ten  London  hospi- 
tals from  1893  to  1907.  The  writer  has  been  able  to  trace  6  more  treated  at  the 
Bristol  Royal  Infirmary  (1900-1912). 


Traumatic    Rupture   of    Intestines. 


Without  Operation 

With  Operation 

Cases 

Died 

Eecovered 

Cases 

Died 

Ilecovered 

< 

London  Hospitals 
Bristol  Royal  Infirmary 

48 

1 

44 
1 

4  =  8% 
0 

84 
5 

67 
1 

17  =  20% 
4 

Many  of  the  patients,  of  course,  were  admitted  moribund,  or  had  fractured 
pelvis  or  spine.  Apart  from  operation,  death  usually  ensued  within  twenty-four 
hours  ;   one  patient  lived  ten  days. 

The  best  results  were  obtained  by  early  operation,  which  means  within  twelve 
hours.  All  the  Bristol  successes  were  treated  from  four  to  six  hours  after  injury  ; 
of  the  London  cases,  13  out  of  33  operated  on  within  twelve  hours  recovered,  but 
only  I  after  the  lapse  of  twenty-four  hours. 

As  regards  site  of  the  injury,  duodenal  tears  were  almost  invariably  fatal. 

It  will  be  observed  that,  even  apart  from  operation,  4  cases  recovered  in  which 
abscesses  or  obstruction,  developing  subsequently,  showed  that  rupture  had 
occurred.  One  patient  got  well  without  operation  who  was  thought  too  ill  to 
have  anything  done  ! 

After  successful  suture,  the  great  majority  of  the  cases  seem  to  remain  quite 
well.  Of  the  Bristol  cases,  3  were  examined  long  afterwards,  and  had  no  trouble 
except  a  slight  incisional  hernia  in  i  case  ;  2  of  these  were  seen  by  the  writer  six 
and  eight  years  after  the  operation.  A  few  of  the  London  cases  returned  for 
obstruction  or  abscesses. 

Ruptured  Liver. — Recent  data  concerning  this  injury  are  not  easy  to  obtain. 
The  writer  has  abstracted  the  records  of  10  cases  treated  at  the  Bristol  Royal 
Infirmary,  of  whom  6  were  operated  on  and  2  recovered.     One  of  the  latter  had 


ABDOMINAL     INJURIES 


a  small  tear,  and  was  not  diagnosed  for  two  days.  The  other  recovery  was 
operated  on  after  five  hours. 

Adding  together  the  statistics  during  ten  years  in  the  Bristol  series,  and  five 
years  at  St.  Thomas's  and  the  Middlesex  Hospitals,  one  obtains  a  record  of  i8 
cases  operated  on,  of  which  12  died  and  6  recovered. 

Tilton  reports  the  figures  from  ten  New  York  hospitals  during  1895  to  1905, 
whereof  7  out  of  12  died  and  5  recovered. 

Ruptured  Spleen. — This  injury  is  less  common  than  the  above.  The  dangerous 
tendency  to  produce  no  alarming  symptoms  for  several  hours  has  already  been 
mentioned. 

Laspeyres  has  found  in  the  literature  58  cases  of  splenectomy  for  rupture,  of 
which  39,  or  67-2  per  cent,  recovered  ;  but  such  records  are  likely  to  be  far  too 
favourable,  as  deaths  are  less  written  up  than  successes. 

Putting  together  the  figures  for  the  Bristol  Royal  Infirmary,  St.  Thomas',  and 
the  Middlesex  hospitals,  one  finds  13  cases  with  8  deaths  and  5  recoveries. 

Ruptured  Pancreas. — This  appears  to  be  a  rare  injury  ;  two  large  London 
hospitals  had  no  case  in  five  years.  At  the  Bristol  Royal  Infirmary  there  have 
been  2  recent  cases  ;  i  died,  the  other  recovered,  and  was  well  four  years  later. 
The  fatal  case  furnishes  an  instance  of  a  common  sequel,  namely,  severe  self- 
digestion  of  the  tissues  leading  to  subphrenic  abscess.  Mikulicz  in  1903  col- 
lected from  the  literature  24  cases,  of  which  13  died  without  operation,  and  of 
the  II  operated  on  7  were  cured. 

Pancreatic  cyst  has  followed  injury  of  this  gland. 

Ruptured  Kidney. — Beall  has  given  to  us  several  tables  of  statistics  collected 
from  the  literature  and  from  hospital  reports  jointl}'',  and  therefore  probably 
rather  too  favourable.  Probably  the  same  cases  are  included  in  several  of  the 
lists.  The  most  useful  figures  are  those  of  Delbet  and  Watson,  which  are  as 
follows.  It  will  be  observed  that  of  cases  not  operated  on  about  two-thirds 
recover,  of  those  submitted  to  nephrectomy  about  three-quarters,  and  all  but 
about  5  per  cent  of  those  explored  but  found  not  to  need  removal  of  the  kidney. 


No  OPEKATION 

Nephrotomy 

NEPHRECToanr 

Cases 

Died 

Per  cent 

Cases         Died       Per  cent 

Cases 

Died       Per  cent 

Delbet 
Watson 

225 
273 

103 

81 

45 
30 

50 
99 

2            4 

7            7 

44 
115 

11              25 

25          22 

When  the  only  evidence  is  a  transient  haematuria,  the  patients  make  a  perfect 
and  complete  recovery. 

When  there  is  in  addition  a  sv/elling  in  the  loin,  but  no  tear  of  the  ureter  and 
no  early  shock  or  haemorrhage,  the  outlook  is  good.  Three  cases,  seen  by  the 
writer  many  years  afterwards,  had  continued  quite  well. 

Marked  signs  of  shock  make  a  bad  prognosis,  whether  the  effusion  of  blood  is 
into  the  loin  or  into  the  peritoneum.  Two  such  cases  at  the  Bristol  Royal 
Infirmary  treated  by  nephrectomy  both  died.  Laceration  of  the  renal  pelvis  or 
ureter  leads  to  leakage  of  urine  or  hydronephrosis,  which  may  suppurate,  when 
the  outlook  becomes  very  grave.  The  outlook  in  children  is  very  grave,  accord- 
ing to  Maas,  85  per  cent  die. 

Rupture  of  Bladder. — This  is  not  very  common.  Two  large  London  hospitals 
had  no  cases  in  five  years.  Of  6  cases  at  the  Bristol  Royal  Infirmary,  only  i 
recovered,  but  usually  the  operation  was  undertaken  too  late  to  give  the  patient 
a  chance.     There  can  be  no  doubt  that  if  there  are  not  severe  injuries  besides. 


INDEX     OF    PROGNOSIS 


and  no  cystitis  is  present,  earty  diagnosis  would  save  a  larger  proportion.  One 
man  fell  into  a  ditch  whilst  intoxicated,  and  ruptured  his  bladder  into  the 
peritoneum.  He  was  treated  by  a  doctor  in  the  country  for  a  week  ;  sometimes 
he  passed  water  himself,  and  sometimes  a  catheter  was  used.  He  was  up  and 
about  most  of  the  time.  On  admission,  the  abdomen  was  greatly  distended  ;  at 
the  operation,  13  pints  of  urinous  fluid  were  evacuated,  and  twelve  sutures  were 
necessarj'  to  sew  up  the  rent  in  the  bladder.  He  died,  but  could  no  doubt  have 
been  saved  by  earlier  operation. 

Collections  of  isolated  cases  from  the  literature,  such  as  Quick's  and  Ashhurst's, 
are  quite  unreliable  in  estimating  the  true  mortality,  because  fatal  cases  so  often 
fail  to  get  into  print.  The  latter  reports  22  cures  out  of  29  cases  operated  on  bv 
various  writers  since  1893. 

2.  Perforating  Wounds. — It  is  not  possible  to  say  much  about  the  prognosis 
of  stab  wounds  of  abdominal  viscera,  because  so  much  depends  upon  the  circum- 
stances and  upon  early  operation.  Given  prompt  diagnosis  and  treatment, 
the  majority  of  the  cases  ought  to  recover,  just  as  a  perforated  gastric  ulcer 
usually  does  ;  but  a  few  hours'  delay,  at  any  rate  beyond  twelve  hours,  will 
seriously  jeopardize  the  patient's  chances.  When  the  signs  of  widespread 
peritonitis  are  present,  the  outlook  is  very  grave,  but  by  no  means  hopeless. 

Statistics  are  not  easy  to  obtain.  Tilton  reports  that  of  13  cases  of  stab  or 
shot  wound  of  the  liver  from  ten  New  York  hospitals,  4  died  and  9  recovered. 
The  prognosis  is,  of  course,  much  better  than  that  of  contusion. 

3.  Gunshot  Wounds  of  the  Abdomen. — The  surgery  of  the  South  African  and 
other  recent  wars  has  greatly  modified  our  conception  of  this  condition.  Everjr- 
one  went  to  South  Africa  expecting  that  there  would  be  a  great  deal  of  abdominal 
surgery,  but  in  practice  the  patients  who  were  shot  through  the  abdomen  did 
far  better  without  operation  than  with.  No  doubt  this  was  partly  due  to  the 
unfavourable  conditions  under  which  operations  and  after-treatment  had  to  be 
conducted.  The  narrow-bore  high-velocity  modern  bullet  makes  only  a  small 
hole  in  the  intestines,  and  peristalsis  is  checked  until  the  track  is  sealed,  so  that 
blameless  recovery  was  the  rule  rather  than  the  exception.  Of  207  cases  of 
gunshot  wound  of  the  abdomen,  143  recovered,  and  in  40  per  cent  of  the  patients 
no  symptoms  of  visceral  injury  ever  developed.  The  principal  factor  in  the 
prognosis  was  transport.  A  long,  rough  journey  to  a  base  hospital  made  the 
outlook  grave.  If  the  patient  was  going  to  die,  he  usually  showed  urgent  sym- 
ptoms of  haemorrhage  or  peritonitis  within  forty-eight  hours.  Those  who  were 
shot  through  a  diameter  of  the  abdomen  usually  died.  Some  of  the  recovering 
cases  developed  a  localized  abscess. 

In  the  days  when  old-fashioned  bullets  and  firearms  were  used,  the  prognosis 
of  abdominal  injuries  was  very  grave.  In  the  American  Civil  War,  90  per  cent 
of  the  cases  died,  and  the  mortality  was  high  in  South  Africa  after  Martini-Henry 
wounds.  In  civil  practice,  patients  shot  through  the  abdomen  with  revolver 
bullets  or  small  shot  will  probably  die  apart  from  operation,  and  even  after  an 
early  laparotomy  there  is  grave  danger. 

With  regard  to  wounds  of  particular  viscera,  the  conclusions  reached  by 
Makins,  based  on  experience  in  the  Boer  War,  were  as  follows  : — 

Wounds  of  small  intestine,  unless  a  diameter  of  the  abdomen  was  perforated, 
usually  got  well.  Wounds  of  colon  were  more  dangerous,  and  a  localized  abscess 
often  formed.  The  prognosis  after  injury  of  the  transverse  colon  was  worse  than 
that  of  the  ascending  colon  or  rectum. 

Wounds  of  the  stomach  usually  recovered. 

In  Avounds  of  the  liver  and  spleen,  unless  they  died  outright  of  haemor- 
rhage,  the  patients  nearly  all  got  well. 


ACIDOSIS 


If  the  kidney  was  traversed,  the  patient  usually  recovered  after  slight  haema- 
turia,  but  in  a  few  cases  hydronephrosis  followed. 

Intraperitoneal  injuries  of  the  bladder  usually  did  well,  but  nearly  all  the  cases 
diagnosed  as  extraperitoneal  perforation  died. 

References. — Rendle  Short,  Lancet,  191 1,  ii,  818  ;  Berry  and  Giuseppe,  Proc.  Roy. 
Soc.  Med.  (Surg.  Sect.),  1909,  iii,  i  ;  Tilton,  "  Ruptured  Liver,"  Ann.  Surg.  1905,  20  ; 
Laspeyres,  Centr.  Grenzg.  1904,  vii,  152  ;  Quick.  "  Ruptured  Bladder,"  Ann.  Surg,  igoy, 
xlv.  94  ;   Makins,  Surgery  of  the  South  African  War  ;   Beall,  Med.   /?ec.  1913,  Ixxxiii,  64. 

A.  Rendle  Short. 

ABSCESS,  SUBPHRENIC. — (See  Subphrenic  Abscess.) 

ACCESSORY  SINUSITIS  OF  THE  NOSE {See  Nasal  Accessory  Sinusitis.) 

ACIDOSIS. — The  prognosis  of  acidosis  depends  more  on  its  cause  than  on 
its  intensity,  though,  ccBteris  paribus,  the  degree  of  the  latter  is  a  most  important 
item.  The  most  common  conditions  in  which  it  occurs  are  diabetes  mellitus, 
starvation,  sudden  withdrawal  of  carbohydrate  food,  after  some  anaesthetics, 
during  febrile  diseases,  in  the  toxsemic  vomiting  of  pregnancy,  the  cyclic 
vomiting  of  children,  and  in  phosphorus  poisoning.  Although  many  factors, 
including  the  administration  of  mineral  acids,  may  lead  to  diminished  alkalinity 
of  the  juices  of  the  body,  and  so  produce  a  state  of  acidosis,  here  we  are  not 
referring  to  such  conditions,  but  to  an  acid  intoxication  set  up  by  the  presence 
of  oxybutyric  acid,  diacetic  acid  and  acetone.  To  this  form  of  poisoning 
children  are  more  susceptible  than  women,  and  the  prognosis  is  worse  in  children 
than  in  women.  Similarly  the  outlook  is  worse  in  women  than  in  men.  These 
bodies  not  only  exert  a  direct  toxic  effect  on  the  tissues  of  the  body,  but  also 
act  detrimentally  on  account  of  their  acid  properties.  In  severe  cases  they  are 
excreted  in  very  large  quantities,  and  this  represents  a  large  quantity  of  unused 
fuel,  entailing  a  considerable  loss  of  energy  to  the  body.  For  purposes  of 
prognosis  it  is  necessary  not  only  to  determine  the  presence  of  acidosis,  but 
also,  so  far  as  is  possible,  the  degree  of  acid  intoxication.  By  the  usual  tests 
the  presence  of  these  substances  will  be  proved  in  the  urine.  Probably  also 
the  odour  of  acetone  in  the  breath  will  be  obvious. 

T.  Stuart  Hart,  in  the  Quarterly  Journal  of  Medicine,  gives  the  following- 
method  for  estimating  the  acidosis  index.  He  first  demonstrates  the  presence 
of  acetone  by  the  usual  test  (Lange's).  Secondly,  he  uses  the  ferric  chloride 
method  (Gerhardt's  test)  to  show  the  presence  of  diacetic  acid.  He  uses  the 
following  solutions  for  the  determination  of  the  acidosis  index  : — 

{a).  The  '  standard  solution,'  consisting  of  ethyl  aceto-acetate  i  c.c,  alcohol 
25  c.c,  and  distilled  water  to  1000  c.c. 

{b).  Ferric  chloride  solution,  consisting  of  100  grams  of  ferric  chloride  dissolved 
in  100  c.c.  of  distilled  water. 

An  equal  quantity  (10  c.c.)  of  (a)  and  of  the  urine  to  be  tested  is  put  into  two 
test-tubes  separately.  To  each  of  these  i  c.c.  of  (6)  is  added.  After  waiting  a 
few  minutes  the  intensity  of  the  colour  of  the  two  is  compared.  If  the  solution 
in  the  {a)  test-tube  is  lighter  than  the  urinary  solution,  add  known  quantities 
of  distilled  water  to  the  latter  till  the  shade  oi  the  two  is  the  same.  From  the 
figures  so  obtained  the  '  acidosis  index  per  litre  '  is  arrived  at. 

Thus  : ■  Acidosis  Inde.\ 

per  litre. 

Lange's  test  positive  and  Gerhardt's  test  negative  =      Oj 
Lange's  test  positive  and  Gerhardt's  test  positive 

Volume  of  urine  solution     10  c.c  =         i 

20    ,,  =^2 

,,  ,,  ,,  100    ,,  =       10 

and  so  on  in  proportion. 


INDEX    OF    PROGNOSIS 


To  obtain  the  'acidosis  index,'  the  'acidosis  index  per  Hfcre  '  is  multipUed  by 
the  amount  of  urine  in  litres  passed  in  twenty-four  hours. 

This  method  gives  an  '  acidosis  index  '  which  can  be  translated  in  terms  of 
/3  oxybutj^ric  acid.  Thus  an  acidosis  index  of  ten  is  equivalent  to  the  daily 
excretion  of  lo  grams  of  i3  oxybutyric  acid. 

Another  helpful  test  is  the  reaction  of  the  patient's  urine  to  alkali  given 
by  the  mouth,  e.g.,  a  patient  who  requires  more  than  i  oz.  a  day  of  sodium 
Ijicarbonate  to  make  his  urine  alkaline,  is  suffering  from  acidosis  of  very  con- 
siderable severity.  In  a  healthy  individual,  2  dr.  of  sodium  bicarbonate  will 
keep  the  urine  alkaline  for  twenty-four  hours.  If,  however,  an  excess  of  acid 
is  being  formed  in  the  body,  the  soda  will  unite  with  the  acid  radicles  and  be 
excreted  in  the  form  of  neutral  salts,  and  thus  fail  to  make  the  urine  alkaline. 
The  amount  of  sodium  bicarbonate  required  to  be  given  to  induce  alkalinity 
helps  materially  therefore  in  forming  a  prognosis. 

The  reduction  in  the  alkalinity  of  the  blood  will  also  give  valuable  indications, 
for  if  this  is  reduced  it  is  almost  certain  that  the  rest  of  the  tissues  have  suffered 
to  a  greater  degree.  The  method  more  frequently  used  at  the  bedside  is  the 
determination  of  the  percentage  of  nitrogen  excreted  in  the  form  of  ammonia, 
and  the  comparison  of  this  percentage  with  the  percentage  of  nitrogen  excreted 
in  the  form  of  urea.  The  ammonia  nitrogen  in  health  is  at  most  about  5  per 
cent  of  the  urinary  nitrogen,  but  in  conditions  of  acidosis  it  not  infrequently 
rises  to  18  to  20  per  cent,  and  readings  as  high  as  40,  50,  or  even  60  per  cent  have 
been  recorded. 

The  nitrogen  is  apparently  excreted  in  the  form  of  ammonium  salts,  instead  of 
being  built  up  in  the  body  into  urea,  in  order  to  neutralize  the  condition  of 
acidosis  in  the  tissues  and  to  save  the  mineral  bases  of  the  body. 

It  must  not,  however,  be  assumed  that  acid  intoxication  exists  because  the 
percentage  of  ammonia  nitrogen  excreted  in  the  urine  is  very  greatly  increased, 
for  this  proportion  may  be  increased,  not  because  there  is  any  absolute  increase 
in  its  amoiint,  but  because  there  is  an  absolute  decrease  in  the  amount  of  urea 
excreted.  This  not  infrequently  happens  in  conditions  of  protein  or  total 
starvation.  It  has  been  found  that  when  the  urea  excretion  faUs  below 
7  to  8  grams  in  the  twenty-four  hours,  the  relative  percentage  of  ammonia 
nitrogen  increases,  and  that  this  may  occur  apart  from  the  presence  of 
organic  acids. 

An  absolute  as  well  as  a  relative  increase  in  the  output  of  ammonia  nitrogen 
must  be  looked  for,  if  this  is  to  be  used  as  a  basis  of  prognosis.  As  much  as 
12  grams  of  ammonia  nitrogen  have  been  observed  to  have  been  excreted  in 
twenty-four  hours,  being  40  per  cent  of  the  total  nitrogen  excreted. 

The  total  quantity  of  ammonia  excreted  forms  an  indication  of  the  degree 
of  acid  intoxication,  but  not  of  necessity  the  amount  of  organic  acid  being 
simultaneously  excreted.  For  the  estimation  of  this,  the  test  of  Hart,  mentione  d 
above,  forms  a  very  useful  guide. 

It  is  of  the  greatest  value  to  make  constant  observations  on  the  percentage 
of  the  ammonia  nitrogen  excretion  in  any  given  case  to  ascertain  if  it  is  running 
into  greater  danger;  but  the  figures  so  obtained  are  of  little  value  in  comparing 
one  patient  with  another,  for  a  man  may  be  in  fairly  good  health  who  is  excreting 
a  much  greater  amount  of  ammonia  nitrogen  than  one  who  is  in  diabetic  coma. 
There  appears  to  be  little  doubt  that  acid  intoxication  is  responsible  for  the 
coma  and  other  toxic  syrriptoms  in  diabetes,  and  kills  the  patient;  but  the 
excretion  of  acetone  bodies  may  go  on  for  many  months  without  acid  intoxica- 
tion supervening. 

In  starvation  the  condition  is  different,  because,  in  spite  of  the  fact  that  the 


ACROMEGALY 


patient  suffers  from  acidosis,  he  can  still  assimilate  and  use  carbohydrates  if 
he  can  get  them,  and  as  he  still  possesses  the  power  of  utilizing  cleavage 
carbohydrate  derived  from  his  own  tissues,  he  probably  dies  rather  from  actual 
deprivation  of  food  than  from  acid  intoxication,  a  point  which  makes  the 
outlook,  as  far  as  treatment  is  concerned,  much  more  hopeful  than  in  the 
corresponding  state  of  diabetes.  In  post-aneesthetic  poisoning  it  must  be 
remembered  that  the  patients  have  generally  been  starved,  and  that  in  starvation 
the  total  excretion  of  ammonia  is  to  be  estimated,  not  merely  the  percentage 
of  the  ammonia  nitrogen,  as  this  may  appear  unduly  high,  owing  to  the  small 
amount  of  urea  excreted. 

The  prognosis  is  much  improved  if  treatment  with  sodium  bicarbonate  and 
glucose  is  used  before  the  administration  of  the  anaesthetic.  Glucose  seems  to 
be  more  effective  than  the  alkali  in  preventing  post-anaesthetic  vomiting. 

When  acidosis  is  present  and  diacetic  acid  excreted,  it  is  said  to  be  a  favourable 
sign  if  the  output  of  diacetic  acid  increases  after  the  administration  of  sodium 
bicarbonate.  This  is  explained  on  the  assumption  that  the  base  unites  with 
the  acid  and  enables  the  acid  to  be  excreted  in  larger  amounts.        /.  R.  Charles. 

ACROMEGALY. — -We  now  believe  that  this  disease  is  due  to  an  excess  of 
secretion  of  the  anterior  lobe  of  the  pituitary  gland,  and  in  many  cases  it  is  found 
that  the  sella  turcica  shows  enlargement  in  the  skiagram,  and  at  the  autopsy 
the  gland  is  usuallj'-  much  increased  in  size.  If  the  symptoms  of  hyperpituitarism 
come  on  before  the  epiphyses  of  the  long  bones  have  united,  gigantism  results. 
We  have  to  consider,  first,  the  natural  prognosis,  and  then  the  effect  of  operation. 
In  the  great  majority  of  cases  there  is  no  immediate  danger  to  life,  and  the 
patient  may  not  even  be  reduced  to  invalidism.  The  profession  is  much  indebted 
to  Dr.  Mark  for  the  graphic  description  he  has  given  us  of  his  own  case.  The 
principal  troubles  are  likely  to  be  neuralgic  pains,  protrusion  of  the  lower  jaw 
interfering  with  eating,  and  some  limitation  of  the  field  of  vision  by  pressure  on 
the  optic  chiasma.  In  other  cases,  symptoms  of  hypopituitarism  follow,  possibly 
due  to  deficiency  of  the  posterior  lobe,  leading  to  iinpotence  in  the  male  and 
amenorrhoea  and  sterility  in  the  female.  The  subjects  of  gigantism  are  generally 
feeble,  and  seldom  live  to  a  great  age. 

There  are  cases,  however,  in  which  the  outlook  becomes  unfavourable  owing 
to  further  increase  in  the  size  of  the  gland  leading  to  intracranial  pressure.  This 
is  much  commoner  in  the  converse  condition  of  hypopituitarism  (Frohlich's  type) 
characterized  by  adiposity  and  atrophy  of  the  genitals  ;  these  patients  are  often 
suffering  from  a  sarcomatous  or  cystic  growth.  When,  therefore,  in  cases  either 
of  acromegaly,  gigantism,  or  Frohlich's  type,  the  patient  complains  of  continuous 
severe  headache,  vomiting,  and  progressive  blindness,  which  are  found  to  be 
associated  with  slow  pulse  and  optic  neuritis  or  atrophy,  it  is  probable  that 
death  is  not  far  off.  The  cases  of  hypopituitarism  are  more  ominous  than  those 
of  acromegaly. 

Prognosis  of  Operation. — The  operation  mortality  is  not  so  high  as  one  might 
suppose  from  the  inaccessible  situation  of  the  gland.  Von  Eiselsberg  reports 
1 6  cases  with  4  deaths  (from  acute  meningitis).  Gushing  avoids  opening  the 
nasal  sinuses  so  as  to  reduce  the  risk  of  sepsis,  and  has  only  lost  10  per  cent  out 
of  61  operations  ;  several  of  the  patients  were  already  desperately  ill.  The 
purpose  of  the  operation  was  to  relieve  pressure  by  decompression,  the  base  of 
the  pituitary  fossa  being  removed  ;  in  other  cases,  part  of  the  gland  was  excised, 
or  a  cyst  evacuated.  If  the  signs  of  intracranial  pressure  are  marked  and 
generalized,  a  subtemporal  decompression  gives  more  relief. 

With  reference  to  the  eventual  results,   von   Eiselsberg  claims  that  all   his 


INDEX     OF     PROGNOSIS 


recovered  cases  were  greatly  relieved  of  their  headache  and  amaurosis  ;  he 
followed  some  of  them  as  long  as  four  years  afterwards. 

Gushing  records  improvement  in  half  of  his  cases.  Both  observers  remark 
that  the  bony  enlargements  of  acromegaly  may  show  reduction. 

Glandular  feeding  does  no  good  in  acromegaly  and  gigantism.  In  cases  of 
the  Frohlich  type,  feeding  or  injection  is  occasionally  followed  by  remarkable 
benefit. 

References. — Gushing,  PitiUiary  Body  and  its  Disorders  ;  Von  Eiselsberg,  Arch.  f. 
klin.  Chir.  1912,  Dec.  8.  '  ^.  ^^^^/^  ^hort. 

ACTINOMYCOSIS.— It  is  probable  that  under  this  clinical  term  various 
forms  of  streptothricosis  are  also  included,  but  it  is  not  clear  that  there  is  an},- 
marked  difference  in  behaviour. 

The  prognosis  depends  principally  upon  two  factors :  the  location  of  the 
disease,  and  the  degree  of  septic  infection  which  has  supervened.  To  some 
extent  also  the  nature  of  the  treatment  controls  the  end-result. 

Actinomycosis  of  the  Appendix  and  Caecum. — This  forms  a  fairly  well-defined 
clinical  group,  of  which  the  writer  has  seen  6  cases,  and  reported  2  more, 
in  the  wards  of  the  Bristol  Royal  Infirmary.  Up  to  1907  there  were  about 
150  cases  in  the  literature,  of  which  27  were  British,  but  it  is  certain  that  the 
real  frequency  is  much  greater.  In  about  60  per  cent  of  cases  of  abdominal 
actinomycosis  this  region  is  affected.  The  outlook  is  very  grave.  Grill 
reported  77  cases,  whereof  22  were  said  to  be  cured,  10  relieved,  and  45  died  ; 
but  it  is  probable  that  this  estimate  is  too  favourable,  in  that  the  cases  were  not 
followed  long  enough.  Patients  of  Gangolphe,  Waring,  and  Blascko,  and  2 
seen  by  the  writer,  were  apparently  cured  or  relieved  for  months  or  years,  but 
the  disease  returned,  in  one  of  the  writer's  cases  after  eight  years,  and  death 
resulted.  There  are,  however,  a  few  authentic  cures.  The  eight  Bristol  cases 
all  died. 

The  course  of  the  illness  is  miserably  chronic  in  the  majority  of  cases,  though 
some  have  died  in  a  few  weeks  or  months.  Beginning  like  an  ordinary  appendi- 
citis, or  occasionally  with  attacks  of  diarrhoea,  a  huge  resistant  mass  gradualh- 
forms  in  the  right  iliac  fossa,  and  abscesses  open  and  burst  through  the  skin. 
The  pain  is  not  great.  By  degrees  the  fungus  spreads  over  the  whole  abdomen, 
metastases  appear  in  or  about  the  liver,  and  usually  death  from  septic  absorption 
follows  in  about  nine  to  twelve  months.  By  this  time  abscesses  may  have 
opened  into  the  bowel,  bladder,  or  other  organs,  producing  faecal  or  urinar}' 
fistulse. 

Abdominal  Actinomycosis  in  other  Localities. — Next  to  the  right  iliac  fossa, 
the  ray-fungus  most  commonly  affects  the  liver,  and  may  come  through  the 
chest  wall,  as  in  a  case  seen  by  the  writer.  Almost  any  other  organ  in  the 
abdomen  may  be  affected,  but  rather  uncommonly. 

The  prognosis  is  unfavourable,  but  not  hopeless.  Jiron  (quoted  by  Keen) 
gives  the  death-rate  in  abdominal  actinomycosis  as  71  per  cent,  which  is  prob- 
ably too  flattering,  as  figures  taken  haphazard  from  the  literature  are  apt  to  be. 

Actinomycosis  of  the  Face,  Jaw,  and  Tongue. — This  is  a  common  location, 
and  a  relatively  favourable  one  if  the  diagnosis  is  made  reasonably  early.  Huge 
swelling,  with  much  induration  but  little  pus,  fixed  to  the  jaw  (usually  the  lower), 
but  extending  widely  into  the  cheek  or  tongue,  with  a  tendency  to  form  sinuses, 
characterizes  the  disease.  Given  efficient  treatment,  however,  it  can  usually 
be  controlled,  though  it  will  be  months  before  the  patient  is  well  again. 

Jiron  quotes  the  mortality  in  this  situation  as  1 1  per  cent  ;  here  again  the 
figure  is  probably  too  favourable. 


ADDISON'S    DISEASE 


Pulmonary  Actinomycosis. — The  fungus  may  attack  the  lungs,  or  appear  in 
the  chest  wall,  forming  a  spongy  abscess.  In  either  case  the  outlook  is  very 
grave.  Hodenpyl  collected  34  cases,  of  which  32  died.  The  duration  of  life 
is  about  six  to  twelve  months. 

Jiron  reports  that  cases  from  the  literature  show  a  mortality  of  83  per  cent 
in  thoracic  cases. 

Actinomycosis  of  the  Brain. — This  is  rare,  and  appears  to  be  rapidly  fatal. 

Actinomycosis  of  tlie  Skin. — This  is  a  favourable  location,  and  though  it 
may  be  very  chronic,  the  considerable  majority  of  the  cases,  if  treated,  are 
eventually  cured. 

The  Effect  of  Treatment. — The  outlook  is  most  favourable,  of  course,  in 
situations  where  a  radical  removal  can  be  undertaken,  but  actinomycosis  of 
the  appendix  has  several  times  recurred  in  the  stump. 

Potassium  iodide  in  large  doses  (240  gr.  a  day  for  months  at  a  time)  probably 
exerts  a  real  curative  effect,  and  the  United  States  Commission  reported  that 
it  cured  63  per  cent  cases  in  cattle.  Copper  salts,  which  are  very  poisonous 
to  algae  and  moulds,  are  recommended  both  locally  and  by  mouth,  but  statistics 
are  not  available.  The  best  results  are  obtained  by  a  combination  of  these 
methods  with  surgery. 

References. — Keen's  Surgery,  vol.  i,  article  "  Actinomycosis  "  ;  Jiron  (reference 
not  found  :  incorrectly  given  by  Keen)  ;    A.  Rendle  Short,  Lancet,  1907,  ii.  p  760. 

A.  Rendle  Short. 
ACUTE  YELLOW  ATROPHY  OF  THE  LIVER.— (5ee  Liver.) 

ADDISON'S  DISEASE.— In  gauging  the  influence  of  treatment  in  Addison's 
disease,  it  must  be  borne  in  mind  that  periods  of  improvement  occur  spon- 
taneously, and  may  be  erroneously  explained  as  due  to  therapeutic  measures. 
In  this  connection  the  generally  admitted  difficulty  in  foretelling  a  successful 
response  to  treatment  in  a  given  case  is  significant.  Further,  as  in  other  grave 
organic  diseases,  the  inauguration  of  treatment  is  often  followed  by  transient 
improvement,  due  more  to  auto-suggestion  than  to  any  specific  action  of  the 
drug. 

General  Treatment. — The  avoidance  of  fatigue  and  worry  is  always  essential, 
and  in  advanced  stages  absolute  rest  in  bed  is  most  important,  to  prevent  sudden 
fatal  syncope.  A  patient  whom  I  saw  ten  years  ago  with  characteristic  sym- 
ptoms is  still  alive,  but  has  been  in  bed  for  eight  years.  Although  open-air 
treatment  has  done  good,  and  is  reasonable  on  the  ground  that  most  of  the  cases 
show  tuberculosis  of  the  adrenals,  protection  from  cold  and  exposure  must  be 
insured.  Healthy  and  cheerful  surroundings,  with  sun  and  warmth,  by 
improving  the  general  health  and  resistance,  have  an  obvious  bearing  on  the 
prognosis.  In  a  few  instances,  of  which  Gaucher  and  Gougerot^  have  collected 
six  examples,  syphilis  appears  to  be  the  causal  factor,  and  in  these  circumstances 
it  is  reasonable  to  hope  that  improvement  will  follow  careful  antisyphilitic 
medication ;  but  these  patients  bear  mercury  badly,  and  the  administration  of 
salvarsan  would  be  a  very  risky  proceeding. 

Organo-therapy  in  this  disease  is  very  disappointing  as  compared  with  the 
results  in  myxoedema.  A  small  proportion  of  cases  are  permanently  benefited 
or  cured,  marked  improvement  occurs  in  some  instances,  and  that  there  is  a 
real  relation  between  the  two  is  borne  out  by  the  onset  of  relapses  when  the 
treatment  is  stopped,  and  by  improvement  when  it  is  resumed  ;  on  the  other 
hand,  relapses  and  even  death  may  occur  during  treatment.  In  nearly  half  the 
reported  cases,  treatment  does  not  exert  any  influence,  and  in  a  few  instances 


INDEX    OF    PROGNOSIS 


alarming  symptoms  appear  to  be  due  to  the  administration  of  suprarenal 
products.  That  arterial  lesions  comparable  to  those  produced  experimentally 
may  be  caused  in  Addison's  disease  by  adrenal  medication  is  unlikely,  though 
Loeper  and  Crouzon^  report  a  case  bearing  this  interpretaton.  Adams''  critical 
analysis  of  112  collected  cases  of  Addison's  disease  treated  by  suprarenal 
medication  shows  that  in  6,  or  5-35  per  cent,  permanent  benefit  or  cure  resulted  ; 
in  33,  or  29-5  per  cent,  marked  improvement  followed  ;  in  49,  or  43"75  per  cent, 
no  effect  was  noted  ;  and  in  7,  or  6-25  per  cent,  alarming  symptoms  were  due  to 
the  treatnient. 

Tuberculin  Treatment. — Although  cases  thus  treated  may  undoubtedly 
improve  or  appear  to  be  almost  cured,  as  in  Munro's*  patient  whom  I  saw,  it 
must  be  remembered  that  even  small  doses  of  tuberculin  may  cause  alarming 
symptoms,  and  probably  for  this  reason  the  number  of  reported  cases  is  very 
small.  The  prognosis  in  cases  thus  treated  is  complicated  by  the  difficult}'  of 
determining  that  a  given  case  is  due  to  adrenal  tuberculosis.  Cases  of  tuber- 
culous disease  of  the  adrenals  may  fail  to  show  any  improvement  after 
tuberculin. 

Operative  Treatment  would  appear  to  be  entirely  contra-indicated  by  the 
liigh  grade  of  asthenia  characteristic  of  the  fully-developed  disease,  and  has  onl}' 
been  attempted  in  isolated  cases.  A  tuberculous  adrenal  which  formed  a 
palpable  tumour  was  renioved  from  a  woman  with  the  constitutional  signs 
but  without  the  pigmentation  of  the  disease,  and  recovery  followed  (Oestreich)." 
Transplantation  of  an  animal's  adrenal  into  the  testis  of  a  patient  with  Addison's 
disease  was  carried  out  by  Busch  and  Wright,^  who  reported  some  improve- 
ment ;    but  death  occurred  two  and  a  half  weeks  after  the  operation. 

Prognosis  in  Individual  Cases. — Addison's  disease,  when  so  well  established 
that  it  can  be  confidently  diagnosed,  appears  to  be  almost  always  fatal  sooner 
or  later  ;  but  it  is  well  known  that  very  considerable  lesions  of  the  suprarenals 
may  be  entirely  latent,  or  may  exist  without  any  sj'mptoms,  and  that  some 
degree  of  suprarenal  inadequacy  or  '  Addisonism,'  especially  in  chronic 
pulmonary  tuberculosis,  in  which  the  symptoms  suggest  but  fall  short  of  those 
in  Addison's  disease,  may  be  a  temporary  condition  (Boinet).'  The  diagnosis 
in  the  early  stages  is  difficult ;  but  while  the  possibility  of  error  must  be  frankly 
admitted,  cases  diagnosed  by  thoroughly  competent  physicians  may  recover 
and  remain  perfectl}'  well.  Thus,  I  know  a  distinguished  phj^sician  who  was 
diagnosed  as  a  case  of  Addison's  disease  by  Greenhow,  a  well-known  authority 
on  the  disease,  more  than  thirty  years  ago,  and  who  has  been  a  great  athlete 
and  is  now  in  perfect  health.  Out  of  293  cases  collected  by  Lewin*  in  1892, 
cure  was  stated  to  have  occurred  in  ten.  It  is  therefore  probable  that  arrest 
may  occur  after  initial  sj^mptoms  of  slight  intensity  have  been  noticed. 

The  average  duration  of  symptoms  in  Wilks'^  cases  was  eighteen  months,  but 
some  of  these  cases  ran  a  very  acute  course.  On  the  other  hand,  survival  for 
ten  or  even  more  years  after  the  onset  of  sj^mptoms  has  been  recorded.  The 
jnost  acute  cases  are  those  in  which  the  suprarenals  are  already  damaged,  usually 
by  tuberculous  infiltration,  but  in  which  symptoms  are  absent  until,  as  the  result 
of  some  acute  infection  or  toxaemia,  the  available  chromaffin  substance  is 
paralyzed,  so  that  symptoms  burst  out  in  a  fulminating  manner,  leading  to  death 
in  a  few  days  or  weeks.  Between  the  very  chronic  and  the  fulminating  cases 
there  are  intermediate  groups  which  contain  most  of  the  cases.  Cases  of  simple 
atrophy  of  the  adrenals  appear  to  run  a  more  rapid  course  than  the  more  usual 
cases  in  which  the  glands  are  invaded  by  tuberculosis.  Possibly  this  is  because 
there  is  atrophy  of  the  whole  chromaffin  system,  which  thus  prevents  any 
compensatory  hypertrophy. 


ALBUMINURIA 


Pigmentation,  which  usually  suggests  the  diagnosis,  is  much  less  important 
than  asthenia  as  a  guide  to  the  course  of  the  disease ;  in  fact,  the  most  acute 
cases  are  commonly  free  from  bronzing.  In  children,  the  disease  is  both  rarer 
and  runs  a  more  rapid  course  than  in  adults  ;  it  is  said  that  two-thirds  of  the 
cases  in  children  last  less  than  a  year  (Castaigne  and  Simon^*').  The  outlook  is 
obviously  worse  in  cases  which  steadily  progress  down-hill  than  in  those  which 
have  periods  of  remission. 

Danger  Signals. — Great  asthenia  and  collapse,  excessively  subnormal  tempera- 
ture, yawning,  low  arterial  blood-pressure  (e.g.,  a  systolic  blood-pressure  of 
65  mm.  Hg),  and  disappearance  of  the  radial  pulse,  point  to  imminent  dissolution. 
I  have  twice  found  the  radial  pulse  absent,  and  in  both  instances  death  followed 
within  thirty-six  hours.  Severe  vomiting  and  diarrhoea,  and  acute  abdominal 
crises  which  may  imitate  appendicitis,  are  also  grave  signs.  The  onset  of  acute 
infections,  such  as  influenza  or  pneumonia,  makes  the  outlook  almost  hopeless. 
A  high  differential  count  of  lymphocytes  has  been  regarded  as  an  unfavourable 
sign ;  this  is  probably  because  it  points  to  the  co-existence  of  the  status 
lymphaticus  which  favours  sudden  syncope  or  death. 

References. — ^Gaucher  et  Gougerot,  Ann.  des  mal.  ven.,  Paris,  1911,  xvi,  321  ; 
^Loeper  et  Crouzon,  Bull.  Soc.  anat.,  Paris,  1903,  s.  6,  v,  918  ;  ^Adams,  Practitioner, 
1903,  Ixxi,  472  ;  *Munro,  Brit.  Med.  Jour.,  1912,  i,  665  ;  ^Oestreich,  Zeits.  f.  klin.  Med., 
Berlin,  1897,  xxxi,  123  ;  *Busch  and  Wright,  Arch.  Int.  Med.,  Chicago,  1910,  v,  30  ; 
'Boinet,  Rev.  de  med.,  Paris,  1897,  xvii,  136  ;  ^Lewin,  Chariie-Ann.,  Berlin,  1892,  xvii, 
536  :  *Wilks,  S.,  System  of  Medicine  (Reynolds^,  1879,  v,  359  ;  ^"Castaigne  et  Simon, 
I.a  pratique  des  maladies  des  enfants,  1910,  iii,  307.  ^_  £>_  Rolleston. 

ALBUMINURIA  {see  also  Nephritis). — The  question  of  prognosis  when 
albuminuria  is  present  must,  in  the  first  place,  depend  entirely  on  accurate 
diagnosis.  Albuminuria  may  result  from  contamination  of  the  urine  by  an 
albuminous  liquid,  such  as  blood,  pus,  or  spermatic  fluid.  Such  albuminuria 
is  spoken  of  as  spurious,  false,  or  accidental  albuminuria,  and  should  be 
sharply  differentiated  from  true  albuminuria,  where  the  albumin  enters  the 
urine  from  the  glomeruli  or  uriniferous  tubules.  The  differentiation  between 
spurious  and  true  albuminuria  does  not,  as  a  rule,  present  any  great  difficulties, 
for  a  contaminating  fluid  usually  contains  a  very  large  number  of  cell-elements, 
which  form  a  sediment  on  standing,  leaving  a  clear  supernatant  fluid  which 
contains  but  a  small  proportion  of  albumin.  Again,  microscopic  examination 
of  the  sediment  will  aid  differentiation  ;  and  tissue-elements  may  be  present 
which  do  not  belong  to  the  urine.  The  occurrence  of  true  pus-cells  in  large 
numbers  points  to  an  inflammatory  affection  of  the  urinary  passages ;  for 
though  polymorphonuclear  leucocytes  are  found  in  the  sediment  of  a  nephritic 
urine,  they  are  never  present  in  large  numbers.  When  a  diffused  nephritis 
occurs  in  combination  with  an  inflammatory  affection  of  the  urinary  passages, 
the  supernatant  urine  will  contain  a  large  proportion  of  albumin.  When  false 
albuminuria  is  present  in  association  with  a  chronic  interstitial  nephritis,  the 
proportion  of  albumin  in  the  supernatant  fluid  may  be  small,  and  diagnosis 
may  present  difflculties  :  consideration  of  the  total  quantity  of  urine,  and  the 
condition  of  the  cardio-vascular  system,  together  with  estimation  of  the  blood- 
pressure,  will  always  give  valuable  data  for  guidance  in  diagnosis. 

Physiological  Albuminuria. — There  can  be  no  doubt  that,  if  the  tests  used  be 
sufficiently  sensitive  and  delicate,  albumin  can  be  demonstrated  in  a  large 
number  of  normal  urines  ;  and  it  is  now  held  that,  though  albumjn  cannot  be 
demonstrated  in  every  healthy  urine,  yet,  under  physiological  conditions — 
conditions  quite  within  the  limits  of  health — it  may  appear  in  such  quantity  as 
to  be  easily  demonstrable  by  ordinary  tests.     This  form  of  albuminuria  occurs  in 


INDEX     OF     PROGNOSIS 


healthy  individuals  before  middle  life,  at  intervals,  and  only  in  response  to  some 
definite  stirmilus  or  strain,  such  as  a  heavy  meal,  unusual  exertion,  cold  bathing, 
mental  excitement,  etc.  If  the  urine  be  examined  with  the  centrifuge,  a  few 
hyaline  casts  and  cylindroids  will  be  found,  but  no  epithelial  or  granular  casts. 
The  albuminuria  in  such  cases  has  no  definite  pathological  significance,  and  the 
prognosis  is  good.  Take,  for  instance,  the  athlete  at  the  commencement  of 
training  :  exertion  may  produce  albuminuria,  but  as  training  proceeds,  similar 
exertion  may  no  longer  produce  it. 

Cyclical  Albuminuria  is  distinguished  from  the  physiological  variety  by  the  fact 
that  no  special  exciting  factor  is  required  for  its  production,  and  the  condition 
cannot  truly  be  considered  physiological.  It  occurs  in  young  persons,  who  are 
frequently  of  poor  nutrition  and  with  a  somewhat  defective,  atonic  digestion. 
The  urine  shows  a  fairly  high  specific  gravity,  easily  deposits  urates,  and  contains 
albumin.  The  latter  follows  a  recognized  cycle  :  on  rising,  the  urine  is  free  from 
albumin  ;  but  it  appears  during  the  morning  hours  ;  it  reaches  a  maximum  in 
the  early  afternoon  ;  and  it  diminishes  in  the  evening.  The  centrifuged  deposit 
may  show  a  few  h^^aline,  but  never  epithelial,  casts.  Cardio-vascular  changes 
are  entirely  absent,  and  the  blood-pressure  is  not  above  the  normal.  In  these 
cases  the  prognosis  is  favourable.  The  patients  are  somewhat  weakly  individuals, 
whose  digestion  requires  care  and  attention,  but  they  do  not  ultimately  develop 
nephritis.  Under  care  they  may,  and  do,  enjoy  good  health ;  though  the 
albuminuria  may  persist  for  years,  it  ultimately  disappears,  and  the  expectation 
of  life  seems  unaffected  by  the  condition. 

Febrile  Albuminuria. — During  an  acute  infectious  disease,  it  is  common  to  get 
a  small  quantity  of  albumin  in  a  urine  which,  otherwise,  does  not  give  the 
characters  of  a  nephritic  urine.  It  is  possible  that,  in  such  cases,  circulatory 
disturbances  may  come  into  play  ;  but  the  main  causal  factor  is  cloudy  swelhng 
resulting  from  infection  and  intoxication.  Strictly  speaking,  such  an  albumin- 
uria must  be  regarded  as  the  first  stage  of  an  infectious  nephritis,  which  may 
or  may  not  develop  into  a  definite  nephritis.  The  presence  of  the  albuminuria 
shows  that  the  fever  has  had  a  marked  effect  on  the  organism.  The  general 
condition  of  the  patient  is  often  serious  :  the  temperature  is  high,  the  pulse 
frequent,  and  dyspnoea  and  collapse  may  supervene.  Most  of  these  symptoms 
are,  however,  dependent  upon  the  general  disease,  and  not  upon  the  renal 
disturbance.  Prognosis  will,  therefore,  be  governed  by  the  general  condition. 
The  albuminuria  is  merely  an  expression  of  the  profound  nature  of  the  general 
disturbance,  which  has  given  rise  to  cloudy  swelling  of  the  tubular  epithehum. 
In  the  large  majority  of  cases,  febrile  albuminuria  does  not  develop  into  definite 
nephritis,  but  disappears  vnth  improvement  in  the  general  condition. 

Albuminuria  of  non-febrile  General  Disease  is  found,  especiallj-,  in  diseased 
conditions  involving  the  blood,  such  as  anaemia,  leukaemia,  scorbutus,  and 
jaundice.  The  albuminuria,  in  such  conditions,  is  largely  to  be  accounted  for 
by  the  blood-condition  and  the  circulatory  disturbances  which  so  often  accom- 
pany the  primary  disease.  It  is  true  that,  in  a  certain  number  of  cases,  epithelial 
changes  have  been  found  in  the  kidneys  ;  but  these  are  by  no  means  constant. 
As  a  rule,  prognosis  will  be  guided  by  the  general  condition  of  the  patient.  The 
albuminuria  is  an  expression  of  profound  disturbance,  and  will,  therefore,  be  a 
factor  to  be  taken  into  consideration  in  guiding  prognosis. 

Albuminuria  occurring  in  the  course  of  diabetes  mellitus  seems  to  stand  in  a 
different  category.  It  has  been  ascribed  to  the  excessive  ingestion  of  eggs  ;  but, 
in  the  majority  of  cases,  it  is  the  expression  of  an  insidious  nephritis  of  the 
interstitial  variety,  and  the  patients,  for  the  most  part  past  middle  life,  show 
cardio-vascular  changes.     The  question  of  prognosis  is  a  mixed  one  ;    for  when 


ALBUMINURIA     OF     PREGNANCY 


interstitial  nephritis  develops  in  the  course  of  diabetes,  amelioration  may  take 
place  in  the  diabetic  symptoms  and  glycosuria  may  disappear.  The  prognosis 
then  becomes  that  of  chronic  interstitial  nephritis  complicated  wdth  hyper- 
glycaemia  ;    that  is  to  say,  it  is  always  grave. 

Albuminuria  due  to  Circulatory  Disturbances  is  common  in  cases  of  cardiac 
disease  with  loss  of  compensation  and  passive  congestion  of  the  kidneys.  In 
these  cases,  imperfect  circulation  leads  to  deficient  oxidation  and  secondary 
changes  in  the  renal  epithelium.  An  additional  causal  factor  will  be  found  in 
increased  pressure  in  the  renal  veins.  The  quantity  of  albumin  present  is  usually 
small,  and  examination  of  the  centrifuged  deposit  will  exclude  nephritis. 
Prognosis  will  depend  upon  the  influence  of  therapeutic  measures  in  improv- 
ing the  circulatory  condition  ;  with  improved  general  circulation,  kidney 
function  is  re-established,  and  a  diuresis  follows,  with  disappearance  of  the 
albuminuria. 

Proteinuria. — Bence- Jones'  proteinuria,  in  the  majority  of  cases,  occurs  in 
instances  of  multiple  myelomata  ;  though  it  has  been  found  associated  with 
other  pathological  conditions,  such  as  leukaemia,  chloroma,  lymphosarcoma, 
myxoedema,  and  carcinomatous  metastasis.  The  recognition  of  the  protein 
depends  upon  its  relatively  easy  precipitation  below  the  boiling  point,  while,  on 
boiling,  the  solution  tends  to  clear.  The  prognosis  depends,  not  on  the  protein- 
uria, but  on  the  primarj^  disease.  As  a  rule,  it  is  utterly  bad  ;  many  sufferers 
only  survive  the  recognition  of  their  conaplaint  a  few"  months.  Cases  are  on 
record  of  a  much  longer  duration,  however  ;  one,  indeed,  where  the  condition 
persisted  twelve  years,  and  the  patient  appeared  to  enjoy  fair  health.  Such 
cases  are,  however,  exceptional  ;  as  a  general  rule,  the  recognition  of  proteinuria 
justifies  a  very  grave  prognosis.  Francis  D.  Boyd. 

ALBUMINURIA  OF  PREGNANCY  (see  also  Eclampsia).— The  frequency 
with  which  alouminuria  occurs  is  variously  given.  The  majority  of  reporters 
place  the  figure  at  lo  per  cent  of  all  pregnancies,  but  Jaeger^  finds  it  present  in 
70  per  cent  of  the  women.  This  figure  is  certainly  abnormally  high,  and  the 
albumin  is  only  to  be  detected  by  careful  examination,  and  often  only  indicates 
a  transient  catarrh  of  the  bladder.  Albuminuria  with  casts  was  present  in 
7-3  per  cent  of  women  in  the  Johns  Hopkins  Hospital  cases. 

Now,  at  the  outset,  one  wants  to  know  what  proportion  of  the  cases  go  on 
to  eclampsia.  There  are,  unfortunately,  no  recent  figures  obtainable,  and 
earlier  observers  gave  70  per  cent  as  developing  such  symptoms.  The  general 
view  held  at  the  present  day  is  best  expressed  in  the  remarks  of  Tarnier,  who 
said  that  he  had  never  seen  convulsions  supervene  in  a  case  which  had  been 
on  strict  milk  diet  and  rest  for  seven  days.  Unfortunately,  the  milk  regime  is 
not  tolerated  by  pregnant  women  in  some  cases,  and  in  others  the  patient  cannot 
be  induced  to  submit  to  it.  Consequently  it  will  be  necessary  to  consider  the 
prognosis  from  the  point  of  view  of  (i)  The  clinical  features  ;  (2)  The  examina- 
tion of  the  urine  ;  and  (3)  The  duration  of  treatment.  The  prognosis  in  respect 
of  (4)   The  fcetus  must  also  be  considered. 

I.  The  Clinical  Features  which  should  especially  arouse  anxiety  are  those 
commonly  grouped  under  the  heading  of  '  pre-eclamptic,'  which  include  troubles 
of  vision,  amblyopia  and  transient  blindness,  severe  persistent  headache,  haemor- 
rhages such  as  epistaxis,  and  finally  epigastric  pain.  In  addition,  an  oedema 
originally  confined  to  the  lower  half  of  the  body,  but  now  extending  to  the 
upper  limbs  and  to  the  face,  is  an  indication  of  at  any  rate  severe  albuminuria. 
The  development  of  such  symptoms  while  under  active  treatment,  should  call 
for  more  energetic  measures.     Bailey-  finds  that  the  blood-pressure  is  raised  in 


14"  INDEX     OF    PROGNOSIS 

the  more  marked  cases  of  albuminuria,  and  a  pressure  exceeding  150   mm.  Hg 
is  to  be  taken  as  indicating  an  impending  eclamptic  seizure. 

2.  The  Urine,  beyond  the  daily  reading  of  the  quantity  of  albumin,  will  serve 
as  a  guide  to  the  patient's  condition  by  the  total  quantity  of  urine  passed  in 
the  twenty-four  hours,  together  with  the  amount  of  urea  excreted.  With  a 
defective  excretion  of  urea  in  a  urine  diminishing  in  quantity,  the  question  of 
terminating  labour  should  be  considered. 

3.  The  Treatment  may  be  complicated  by  the  fact  that  some  people  cannot 
take  milk.  In  these  cases  good  results  are  reported  as  following  the  administra- 
tion of  a  salt-free  diet. 

If  with  rest,  purgation,  and  careful  dieting  the  condition  becomes  aggravated, 
then  it  becomes  necessary  to  adopt  measures  for  interrupting  the  pregnancy. 
Many  cases  miscarry'  in  spite  of  treatment. 

4.  Prognosis  as  regards  the  Foetus. — It  is  to  be  remembered  that  the  fre- 
quency of  prem„ature  labour  lowers  the  chance  of  survival,  and  further  that  the 
occurrence  of  placental  hasmorrhages,  which  are  often  seen  in  albunainuria  of 
pregnancy,  are  said  to  endanger  the  life  of  the  fcetus,  so  that  in  many  instances 
the  child  is  still-born  and  even  macerated. 

References. — ^Zeits.  f.  Geb.  u.  Gyn.  Ixviii,  Hft.  3  ;  ^Surg.  Gyn.  and  Obst.  191 1,  Nov. 

Bryden  Glendining. 
ALCOHOLISM. — {See  Mental  Diseases.) 

ANiEMIA,  APLASTIC. — -This  condition  is  apparently  due  to  an  exhaustion 
of  the  bone-marrow  or  to  its  inability  to  respond  to  calls  upon  it.  It  follows 
severe  septic  and  toxic  conditions  ;  in  some  of  these  the  anaemia  is  aplastic 
from  the  beginning,  so  that  regeneration  never  takes  place  ;  in  other  cases, 
regeneration  may  first  occur  and  then  fail.  Sometimes  it  has  followed  on 
pernicious  anaemia.  We  have  known  cases  occur  after  repeated  or  continued 
heemorrhage.  In  many  instances  no  causal  condition  can  be  discovered,  and  in 
these  we  may  suppose  that  an  inherent  vulnerability  or  weakness  of  the  marrow 
renders  it  unable  to  respond  to  any  extra  demand  on  its  functions.  In  most 
cases,  however,  aplastic  anaemia  is  to  be  regarded  as  the  terminal  phase  of  a 
serious  disease.  The  only  possible  chance  of  a  favourable  outcome  would  be  the 
discovery  of  a  removable  cause.  This,  however,  is  a  remote  contingency.  As 
a  rule,  a  fatal  termination  may  be  expected  in  a  few  weeks  or  months ;  in  one  of 
our  cases  there  was  a  history  of  anaemia  for  only  three  weeks  before  admission  to 
hospital;  the  red  corpuscles  numbered  1,300,000  per  c.mm.  Death  took  place 
ten  days  later ;  the  red  cells  had  decreased  to  800,000.  Another  case  gave  a 
history'  of  progressive  anaemia  for  two  years  ;  his  red  cell  count  was  625,000. 
Death  occurred  in  seven  weeks,  the  count  having  fallen  to  340,000  per  c.mm. 
Among  the  signs  which  indicate  that  a  fatal  outcome  is  imminent  are  a  low  red 
cell  count  and  a  low  leucocyte  count,  especiall}^  a  diminution  of  the  granular 
cells. 

If  nucleated  red  cells  have  been  present,  and  either  diminish  or  fail  to  increase 
in  number  as  the  red-cell  count  becomes  progressively  lower,  we  would  suspect 
that  the  anaemia  was  aplastic.  In  both  severe  secondary  and  pernicious  anaemia 
we  usually  expect  to  find  that  nucleated  red  cells  become  more  numerous  in  the 
blood  as  the  corpuscular  count  drops.  The  occurrence  of  haemorrhages  is  an 
unfavourable  indication,  and  an  attack  of  intercurrent  disease  renders  a  fatal 

issue  doubly  certain.  G.  L.  Gulland. 

A.  Goodall. 

'  ANAEMIA,  PERNICIOUS.— (See  Pernicious  Anemia.) 


ANEMIA,     SECONDARY  15 


ANEMIA,  SECONDARY. — Secondary  ansemia  may  arise  from  a  great  variety 
of  causes,  and  practically  the  only  condition  in  which  the  prognosis  is  not  more 
influenced  by  the  causal  factor  than  by  the  bloodlessness,  is  post-hajmorrhagic 
anaemia. 

Acute  Post-hsemorrhagic  Anaemia  may  be  immediately  fatal.  No  other 
condition  causes  so  much  anxiety  to  the  patient.  Pallor,  giddiness,  and  faintness 
may  be  noticed  before  much  blood  has  been  lost.  As  soon  as  the  blood-loss  has 
become  severe,  the  pulse  becomes  low  in  tension,  small  in  volume,  and  irregular. 
All  of  these  symptoms  are  readily  recovered  from. 

More  serious  are  hiccough,  nausea  and  vomiting.  Persistent  syncope  is  a 
very  grave  indication.  Fibrillary  tremors  and  delirium  are  of  even  more  serious 
omen,  and  after  convulsions  have  occurred  recovery  rarely  follows. 

If  the  haemorrhage  is  checked  before  a  fatal  result  takes  place,  the  patient  is 
not  yet  out  of  danger.  The  blood  is  diluted  by  fluid  from  the  tissues  and  its  res- 
piratory value  is  thereby  diminished  ;  it  is  also  possible  that  the  resulting 
hydraemia  leads  to  a  destruction  of  some  of  the  less  resistant  corpuscles. 

The  maximum  severity  of  the  anaemia  is  therefore  not  reached  till  some  days 
after  the  actual  haemorrhage,  but  the  danger  to  life  is  not  so  great  as  during  the 
initial  loss  of  fluid.  A  return  of  syncope  and  nervous  symptoms  at  this  stage 
would  be  a  serious  indication.  It  is  hardly  necessary  to  discuss  immediate 
prognosis  in  the  case  of  actual  haemorrhage,  since  the  matter  is  determined  at 
once.  When  a  serious  haemorrhage  has  been  arrested,  it  may  be  of  vast  import- 
ance to  be  able  to  estimate  the  subsequent  course  of  events. 

The  suddenness  of  the  hemorrhage  is  a  factor.  If  blood  be  lost  slowly,  or  in 
two  or  three  repeated  haemorrhages,  the  patient  has  a  better  chance  of  life  than 
if  the  same,  or  even  a  less,  quantity  of  blood  were  lost  rapidly  ;  as,  in  the  former 
case,  there  is  more  time  for  the  relationship  between  the  body-fluids  and  blood- 
pressure  to  be  re-adjusted.  Infants  and  young  children  bear  the  eft'ects  of 
haemorrhage  badly,  but  in  the  cases  which  survive,  regeneration  is  very  rapid 
after  two  or  three  days. 

Elderly  and  weakly  persons  will  obviously  be  worse  subjects  for  a  haemorrhage 
than  the  middle-aged  and  robust. 

In  cases  which  do  badly,  the  appetite  almost  entirely  fails,  there  is  nausea  and 
sometimes  sickness.  The  heart  acts  feebly  and  irregularly,  fainting  occurs, 
with  or  without  change  of  posture,  and  fatal  syncope  ensues.  Patients  are 
querulous  and  irritable,  and  permanent  damage  may  be  done  to  the  nervous 
system.  Among  the  most  distressing  consequences  is  blindness,  sometimes 
due  to  optic  neuritis,  sometimes  to  no  discoverable  lesion.  Such  results  are 
fortunately  very  rare. 

It  is  sometimes  asked  how  much  blood  can  be  lost  without  a  fatal  issue  ensuing. 
This  question  can  hardly  be  answered  ;  so  much  depends  upon  the  suddenness 
of  the  haemorrhage  and  the  age  and  strength  of  the  patient.  It  may  be  said  that 
if  a  robust  adult  is  still  alive  by  the  time  a  haemorrhage  is  arrested,  the  chances 
are  greatly  in  favour  of  his  complete  recovery. 

We  can  recall  the  case  of  a  housemaid  who  was  suddenly  the  subject  of  a  large 
haematemesis.  This  was  repeated  the  following  day.  A  blood  examination 
showed  red  corpuscles  400,000  per  c.mm.  ;  hemoglobin  something  immeasurably 
low — less  than  5  per  cent.  This  case  gave  rise  to  great  anxiety  for  several  days, 
but  the  patient  made  an  uneventful  recovery.  We  hardly  expect  ever  to  see  this 
case  paralleled. 

The  rate  of  blood-regeneration  varies  with  the  severity  of  the  blood-loss  and  the 
condition  of  the  patient.  A  robust  patient  will  replace  a  blood-loss  of  30  to  50 
per  cent  in  a  month  or  six  weeks. 


1 6  INDEX    OF    PROGNOSIS 

Several  months  might  elapse  before  such  a  haemorrhage  was  made  good  in  an 
elderly  or  weakly  person. 

It  is  often  desirable  to  know  the  limits  of  anaemia  which  justify  surgica 
intervention.  Mikulicz  long  ago  laid  it  down  that  operations  should  not  be 
performed  when  the  haemoglobin  percentage  was  under  30.  This  appears  to  us  to  be 
as  just  and  reasonable  as  any  arbitrary  rule  in  medicine  can  be.  The  cases  where 
operation  is  demanded  are  chiefly  those  in  which  the  operation  is  calculated  to 
arrest  haemorrhage.  We  can  quote  the  following.  In  one  instance  hysterectomy 
was  performed  for  bleeding  fibroids  after  the  haemoglobin  percentage  had  fallen 
to  24.  In  another  such  case,  the  blood-examination  before  the  operation  revealed 
red  corpuscles  2,000,000,  haemoglobin  30  per  cent,  leucocytes  15,000.  A  fortnight 
later  the  corresponding  figures  were  2,900,000,  50  and  7500.  It  should  be 
remembered  that,  in  skilful  hands,  hysterectomy  is  practically  a  bloodless 
operation. 

The  blood-examination  may  give  some  guidance  to  the  eventual  outcome  of 
haemorrhage.  A  leucocytosis  beginning  from  eight  to  twelve  hours  after  the 
bleeding  indicates  two  things  :  first,  that  the  haemorrhage  has  been  at  least 
moderately  severe  ;    and  second,  that  the  marrow  is  showing  signs  of  reaction. 

The  appearance  of  nucleated  red  cells  about  the  second  or  third  day  is  also  an 
indication  that  the  haemorrhage  has  been  severe.  Some  guidance  as  to  the 
progress  of  regeneration  may  be  obtained  by  noting  their  relationship  to  thg 
degree  of  anaemia.     A  moderate  number  is  to  be  expected  in  all  severe  anaemias. 

Their  absence  after  repeated  search,  in  a  case  of  severe  anaemia,  would  indicate 
a  slowness  or  deficiency  of  regeneration  on  the  part  of  the  marrow. 

Chronic  Secondary  Anaemia. — The  least  complicated  condition  is  that  due 
to  repeated  hemorrhages.  Among  the  common  causal  factors  are  bleeding  piles, 
menorrhagia  or  metrorrhagia,  gastric  and  duodenal  ulcer,  and  worm  infections. 
These  are  all  curable  conditions,  and  so  far  as  the  anaemia  is  concerned,  it  is 
imperative  that  treatment  should  be  sufficiently  early  and  energetic  to  forestall 
such  a  loss  of  blood  as  would  leave  the  patient  with  a  haemoglobin  percentage  of 
40  or  30.  As  already  seen,  the  latter  is  about  the  lowest  limit  at  which  surgical 
operations  are  practicable.  If  it  is  impossible  to  deal  with  recurrent  bleeding, 
fatty  degeneration  of  the  organs  will  ensue.  The  heart  becomes  feeble  and 
irregular,  appetite  and  digestion  fail,  oedema  becomes  evident,  there  may  be 
petechial  haemorrhages  and  nervous  symptoms.  Death  occurs  from  heart- 
failure  or  from  failure  of  tissue-nutrition.  A  falling  leucocyte  count  and  a 
disappearance  of  nucleated  red  cells  will  indicate  that  the  case  is  becoming  one 
of  aplastic  anaemia  (q.v.). 

Anaemia  due  to  improper  nourishment  and  unfavourable  surroundings  is  not 

usually  very  severe,  and  is  easily  curable  when  the  environment  is  improved. 

Chronic  secondary  anemia  is  also  associated  with  a  variety  of  toxic  conditions- — 

sepsis,    fevers,    syphilis,    malignant   disease,    and   exhausting   diseases   such   as 

nephritis,  chronic  catarrh  of  the  alimentary  system,  and  so  forth.     In  many  of 

these,  the  anaemia  may  become  so  pronounced  as  to  be  an  element  to  be  considered 

in  estimating  the  outcome  of  the  disease,  but  in  all  cases  it  would  be  taking  an 

incorrect  perspective  to  attempt  to  gauge  the  severity  of  the  condition  from  the 

anemia,  rather  than  from  the  broader  point  of  view  of  the  influence  of  the  causal 

condition.  G.  L.  Gulland. 

A.  Goouall. 

ANiEMIA,  SPLENIC. — In  estimating  the  prognosis  of  a  case  of  splenic  anaemia, 
it  is  advisable  to  try  to  distinguish  between  true  splenic  anaemia  or  Banti's 
disease,  due  to  an  overgrowth  of  fibrous  tissue  in  the  spleen,  and  at  a  later  stage 
in  the  liver,  and  primary  splenomegaly  or  Gaucher's  disease,  where  the  essential 


anjEmia.    splenic  17 


lesion  is  a  proliferation  of  endothelioid  cells  in  the  spleen.  The  latter  condition 
is  to  be  suspected,  especially  in  young  subjects,  when  other  members  of  the 
family  have  been  similarly  affected,  when  there  is  a  peculiar  grey  pigmentation 
of  the  skin,  and  when  ansemia  (in  the  initial  stages)  is  slight.  It  may  be  noted, 
in  the  first  place,  that  a  very  few  cases  diagnosed  as  true  splenic  anaemia  by 
competent  observers  have  apparently  recovered  without  operative  interference. 
Goetz^  records  the  case  of  a  girl  who  had  been  deUcate  from  birth.  At  the 
age  of  five  years  an  enormous  enlargement  of  the  spleen  was  discovered. 
The  number  of  red  and  white  corpuscles  was  normal.  Haemoglobin  was 
reduced  to  70  per  cent.  There  were  repeated  attacks  of  haematemesis,  and 
ascites  had  to  be  relieved  by  tapping  on  several  occasions.  The  child  survived 
attacks  of  measles,  bronchopneumonia  and  croupous  pneumonia.  At  the  age 
of  fourteen  an  attack  of  haematemesis  occurred,  but  the  spleen  had  by  this 
time  diminished  in  size.  No  further  symptoms  occurred,  and  three  years 
later  the  spleen  could  not  be  felt  and  the  girl  appeared  to  be  in  perfect  health. 

Winter^  reports  the  case  of  a  man,  aged  35,  whose  spleen  had  been  enlarged 
for  at  least  four  years.  He  had  suffered  from  haematemesis  and  melaena,  and  the 
red-cell  count  fell  to  1,800,000  per  c.mm.  Under  treatment,  the  number  of 
corpuscles  rose  to  4,800,000,  and  the  patient  returned  to  work,  although  the 
spleen  remained  large.  Most  of  such  cases  have  been  treated  with  arsenic,  or 
arsenic  with  iodides. 

Ten  years  ago,  a  youth  of  eighteen,  suffering  from  splenic  anaemia  in  an  early 
stage,  came  under  the  care  of  one  of  us.  Gastro-intestinal  symptoms  were  very 
pronounced,  and  treatment  directed  towards  the  alimentary  canal  led  to  what 
has  apparently  been  a  complete  recovery. 

Such  favourable  results  as  the  foregoing  are  by  no  means  common.  Benefit 
sometimes  follows  the  application  of  x  rays  to  the  spleen,  but  it  must  be 
admitted  that  in  the  majority  of  the  recorded  cases  their  use  has  not  influenced 
the  course  of  the  disease.  We  can  recall  the  case  of  a  girl  of  seventeen  who  had 
a  remission  of  symptoms  for  five  years  after  a  course  of  ;f-ray  treatment. 
Symptoms  then  returned  and  ascites  was  found.  The  further  application  of 
the  rays  failed  to  do  good.  Another  case  is  that  of  a  lady,  aged  fifty,  with  an 
enlarged'spleen.  She  has  had  many  exacerbations,  but  since  the  application  of 
X  rays  she  has  had  a  remission  of  18  months'  duration. 

When  a  case  is  doing  badly,  or  when  the  disease  appears  to  condemn  a  patient 
to  a  life  of  more  or  less  complete  invalidism,  the  problem  of  prognosis  resolves 
itself  into  the  question  whether  removal  of  the  spleen  can  be  safely  accomplished. 
The  outstanding  fact  in  this  connection  is  that  a  large  number  of  thoroughly 
successful  cures  have  been  effected.  Immediate  benefit  has  frequently  followed 
in  cases  previously  doing  badly.  A  few  unsuccessful  cases  have  also  been 
reported,  and  the  presumption  is  that  a  good  many  more  have  been  left  un- 
recorded. Cases  have  died  of  haemorrhage  or  shock  immediately  after  the 
operation  ;  others  have  been  carried  off  by  pneumonia  ;  and  yet  others  have 
died  of  vague  gastro-intestinal  symptoms  after  a  short  interval.  Armstrong^ 
collected  32  cases  of  splenectomy  for  splenic  anaemia.  Complete  recovery 
followed  in  22  instances  ;  a  fatal  result  from  haemorrhage  or  shock  occurred 
in  9  cases ;  i  patient  was  unrelieved.  At  the  discussion  on  the  subject, 
reported  in  the  Proceedings  of  the  Royal  Society  of  Medicine,  June,  1913,  6 
cases  of  splenectomy  were  reported ;  in  all  six  the  patient  recovered  and 
the  anaemia  disappeared.  The  great  majority  of  successful  splenectomies 
have  been  in  young  subjects. 

In  dealing  with  cases  of  splenic  anaemia  it  should  be  remembered  that  its 
course  is  usually  extremely  chronic.     Little  change  may  be  manifested  for  years. 

2 


1 8  INDEX     OF    PROGNOSIS 

Even  a  downward  tendency  is  seldom  progressive.  Exacerbations  may  be 
followed  by  long  remissions,  and  the  patient  may  continue  to  show  little  change. 
The  standard  of  health  after  an  exacerbation  is  likely  to  be  lower,  but  lost  ground 
is  sometimes  recovered. 

The  greatest  danger  lies  in  the  possibihty  of  intercurrent  disease,  and  this  is 
the  usual  cause  of  death.  The  possibility  of  sudden  haemorrhage,  too,  is  always 
a  source  of  danger.  Hcematemesis,  ascites,  and  exhaustion  close  the  normal 
history  of  the  disease. 

The  risk  of  haemorrhage  increases  with  increasing  anasmia,  and  therefore,  in 
cases  where  splenectomy  is  thought  desirable,  the  operation  should  not  be  too 
long  delayed. 

Another  risk  of  delay  is  that  the  result  of  an  intercurrent  affection  naay 
diminish  or  abolish  the  feasibihty  of  surgical  aid.  We  have  seen  one  such  case, 
where  fibrosis  of  the  lung  followed  an  attack  of  pneumonia  and  rendered  the 
performance  of  splenectomy  out  of  the  question. 

Where  operation  is  contemplated,  and  the  presence  of  ascites  might  be  recorded 
as  a  bar,  the  effect  of  a  preliminary  tapping  might  be  tried.  We  have  one  case, 
a  boy  of  sixteen,  suffering  from  splenic  anaemia  of  the  Gaucher  type,  in  whom  a 
single  tapping  has  kept  the  patient  free  from  ascites  for  two  years.  There  is  now 
a  slight  return  of  fluid.  Unfortunately  the  co-existence  of  mitral  stenosis 
precludes  operation  in  this  instance.  In  the  later  stage  of  Banti's  disease, 
splenectomy  combined  with  a  Talma  or  Drummond-Morison  operation  might 
offer  the  chance  of  amehoration.    One  success  has  been  recorded  by  Tansini.* 

In  primary  splenomegaly  (Gaucher),  the  course  may  be  very  prolonged.  In 
Gau Cher's  own  case  the  spleen  had  been  enlarged  for  twenty-five  years.  The 
condition  is  more  common  in  young  subjects,  and  most  of  them  are  carried  off 
by  intercurrent  affections. 

The  data  regarding  splenectomy  are  very  scanty.  A  few  successful  cases  have 
been  recorded,  and  there  appears  to  be  no  alternative  which  offers  a  reasonable 
hope  of  success. 

References. — ^Rev.  Med.  de  la  Suisse  rom.,  1910  ;  -Dub.  Jour,  of  Med.  Sci.,  1912  ; 
^Brit.  Med.  Jour.  1906,  ii_;    *Riforma  med.,   Rome,  1902.  q,  l.  GuUand. 

A.  Goodall. 

ANEMIA,  SPLENIC,  OF  INFANCY.— This  condition  usually  occurs  in  children 
between  the  age  of  ten  months  and  two  years,  and  these  limits  are  very  seldom 
overstepped.  It  is  not  yet  settled  whether  the  splenic  ansemia  of  infants  is  a 
mere  secondary  or  s^^mptomatic  ansemia,  or  a  special  form  occurring  in 
infants.  The  latter  is  probably  the  correct  view.  Although  the  cause  and 
concomitants  may  vary,  the  clinical  picture  and  the  blood-changes  are  constant 
and  definite.  It  is  associated  with  rickets  in  the  great  majority  of  cases.  The 
estimation  of  prognosis  is  not  easy.  Recovery  takes  place  in  a  large  proportion, 
probably  the  majority,  of  cases.  More  cases  die  of  a  complication  than  of  the 
anaemia  itself.  Pneumonia  most  frequently  determines  a  fatal  outcome.  The 
severity  of  the  rickets  or  other  causal  condition,  and  the  general  condition  of  the 
patient,  are  the  chief  guides  to  prognosis. 

Marked  emaciation,  severe  gastro-mtestinal  disturbance,  or  any  complication, 
adds  to  the  gravity  of  the  outlook.  Petechial  haemorrhages  or  other  manifesta- 
tions of  purpura  are  particularly  unfavourable.  The  size  of  the  spleen  gives 
no  indication  of  the  severity  of  the  condition.  The  examination  of  the  blood 
yields  useful  prognostic  indications.  The  most  serious  is  a  very  marked  reduction 
in  the  number  of  the  red  corpuscles ;  counts  below  2,000,000  per  c.mm.  indicate 
dangerous  possibilities,  and  this  is  especially  the  case  if  the  colour  index  is  low. 
The  number  of  nucleated  red  cells  in  the  circulating  blood  appears  to  have  no 


ANESTHETICS  19 


relationship  to  the  severity  of  the  anaemia  or  the  gravity  of  the  prognosis,  nor  is 
it  a  matter  of  practical  significance  whether  the  majority  of  the  erythroblasts 
are  normoblasts  or  megaloblasts.  A  high  leucocyte  count,  e.g.,  over  60,000,  is 
to  be  regarded  as  a  serious  indication.  The  presence  of  a  few  myelocytes  has 
no  special  significance,  but  a  large  number,  or  an  abnormally  high  percentage 
of  lymphocytes,  is  of  more  serious  import.  Fowler  lays  stress  on  the  grave 
significance  of  a  high  proportion  of  transitional  forms.  Other  things  being 
equal,  the  more  nearly  the  leucocyte  picture  approaches  that  of  a  simple 
polymorph  leucocytosis,  the  more  favourable  is  the  case. 

The  best  of  all  prognostic  indications  will  be  provided  by  the  response  to 
treatment.  If  a  case  begins  to  improve,  a  favourable  outcome  may  reasonably 
be  expected.  Good  hygienic  surroundings,  and  treatment  directed  towards  the 
amelioration  of  general  health  and  removal  of  the  causal  condition,  are  more 
likely  to  be  followed  by  good  results  than  mpre  specific  measures. 

Arsenic  and  iron  are  not  so  clearly  indicated  as  in  most  other  ansemias.  They 
may  do  good,  but  they  should  be  employed  with  caution.  The  application  of 
X  rays,  in  our  experience,  does  more  harm  than  good.  Splenectomy  is  not  to  be 
entertained.  The  enlargement  of  the  spleen  persists  long  after  the  anaemia 
has  been  cured.  A  greatly  enlarged  spleen  may  not  become  impalpable  tiU 
after  a  year  has  elapsed. 

Cowan  has  reported  two  cases  in  which  the  condition  appears  to  have  passed 
into  the  adult  form  of  splenic  anaemia.  G.  L.  Gulland. 

A.  Goodall. 

ANESTHETICS. — The  data  required  for  arriving  at  an  accura^te  forecast 
as  to  risk  to  life  under  ansesthetics  and  analgesics  are  at  once  dif&cult  to  obtain 
and  still  more  difficult  to  apply  practically. 

If  we  employ  the  statistical  method,  an  examination  of  the  figures  upon  which 
conclusions  are  based  as  regards  any  given  ancsstheiic  reveals  their  fallacy.  For 
example  :  although  it  is  true  that  the  death-rate  under  chloroform  is  put  at 
about  I  in  3000  when  statistics  collected  by  various  persons  are  added  together, 
yet,  if  we  accept  this  estimate  as  approximately  true,  we  do  not  learn  anything 
about  the  expectancy  of  life  in  any  given  case.  If  we  analyze  the  figures  which 
make  up  the  total,  and  study  the  question  of  the  person  adininistering  the 
anaesthetic,  we  find  that  the  expert's  return  of  deaths  falls  enormously  below 
this  figure.  In  different  countries,  again,  we  are  given  widely  different  figures. 
Those  of  Col.  Lawrie  in  the  case  of  a  considerable  number  of  operations  upon 
natives  in  India,  present  a  far  lower  death-  and  danger-rate  than  those  of  other 
men  of  experience  in  other  countries.  In  the  case  of  ether  we  find  equally 
discordant  results.  One  fact  stands  out  prominently — that  in  countries  or 
districts  in  which  chloroform  is  mainly  used  while  ether  is  the  exception,  the 
death-rate  under  the  former  is  lower  than  in  places  in  which  ether  is  most 
employed  and  chloroform  is  seldom  relied  upon. 

In  individual  hospitals  we  find  that  the  death-rates  differ  ;  and  when  we 
investigate  the  possible  reasons  for  this,  we  find  that  the  death-rate  varies 
directly  as  the  type  of  the  anaesthetist.  When  the  last  is  a  student  who  has 
a  brief  tenure  of  office,  the  results  are  unfavourable  ;  when  special  men  undertake 
the  duties  of  anaesthetist,  and  remain  in  office  for  a  long  time,  or  when  special 
anaesthetists  are  employed,  the  death-rate  is  lowered.  We  may  conclude,  then, 
that  one  factor  of  importance  is  the  anasslhetist.  When  he  is  well  trained, 
and  gives  his  undivided  attention  to  his  work,  the  safety  of  the  patient  is 
greater.  Nor  is  this  due  merely  to  the  hypothesis  that  such  an  individual 
adopts  the  best  methods.  These  methods  vary  within  the  widest  hmits  ;  and 
while  some  persons  will  extol  one  type  of  procedure,  another  will  prefer  one 


INDEX    OF    PROGNOSIS 


which  differs  from  the  other  in  toto  ccbIo.  If  we  compare  the  results  obtained 
by  the  two  men,  they  being  expert  in  their  pecuhar  systems,  we  shall  find 
their  results  practically  identical.  But  if  their  methods  are  pursued  by  a 
large  number  of  students,  most  of  them  lacking  in  experience  and  judgement, 
and  liable  to  errors  of  technique,  we  shall  discover  that  methods  do  really 
constitute  an  important  factor  making  for  danger  or  safety,  for  the  incidence 
of  death  is  favourable  with  some  methods,  unfavourable  with  others. 

Recurring  to  the  administrator  as  a  factor,  we  find,  further,  that  few 
■  experienced  men  at  the  present  day  adopt  one  anaesthetic  or  one  method  to 
the  exclusion  of  all  others,  and  so  the  important  element  of  judgement,  itself  the 
result  of  wide  experience  alike  of  failure  and  success,  comes  to  play  an  important 
part  ;  and  the  selection  alike  of  anaesthetic  and  method  intervenes  and  modifies 
the  incidence  of  danger. 

This  again  introduces  a  third  factor,  the  condition  of  the  patient.  Let  us  make 
this  clear  by  an  illustration.  Nitrous  oxide  gas  is  regarded,  and  rightly  so, 
as  being  the  least  dangerous  of  the  general  inhalational  anaesthetics ;  and  yet, 
if  it  is  employed  for  a  patient  suffering  from  some  obstructive  disease  affecting 
his  air-passages,  e.g.,  angina  Ludovici,  the  risk  to  the  patient's  life  is  infinitely 
greater  than  would  be  the  case  if  chloroform,  an  anaesthetic  at  the  opposite 
pole  to  nitrous  oxide  gas  as  regards  safety,  had  been  employed.  The  inexperi- 
enced man  would  probably  select  nitrous  oxide  gas  for  such  a  case,  pursuing 
general  principles,  and  kill  the  patient  ;  the  experienced  man  would  select 
the  chloroform,    and  save  the  life. 

The  statistical  method  fails  us  in  this  particular.  It  would  record  such  a  death 
as  being  due  to  nitrous  oxide  gas  ;  and  although  such  was  actually  the  fact,  yet 
it  does  not  in  any  way  demonstrate  that  this  anaesthetic,  as  such,  is  less  safe  than 
chloroform  ;  indeed,  the  opposite  is  certainly  true.  It  further  happens  that  in 
many  cases  the  condition  of  the  patient  is  so  serious  that  it  becomes  absolutely 
necessary  either  to  deny  him  the  benefit  of  an  anaesthetic,  and  often  by  so  doing 
increase  his  risk  through  shock,  or  to  select  an  anaesthetic  or  analgesic  which  is 
peculiarly  free  from  risk  to  life.  Under  such  conditions,  many  must  die,  and  the 
statistical  method  would,  by  recording  such  deaths  against  the  practically 
innocuous  anaesthetic,  create  a  spurious  death-rate  for  it. 

In  this  last  illustration  it  will  be  observed  that  a  fourth  factor  has  made 
itself  evident — the  nature  and  gravity  of  the  operaiioyi  for  which  the  anaesthetic 
is  being  administered.  Now,  in  all  the  statistics  at  present  in  our  hands,  the 
grand  totals  merely  reveal  the  actual  number  of  deaths  occurring  under  any 
given  agent  ;  no  account  is  taken,  either  of  the  method  adopted,  itself  often 
as  important  as  the  anaesthetic  ;  of  the  experience  and  ability  of  the  adminis- 
trator ;  of  the  nature  of  the  operation — for  example,  whether  it  was  upon 
the  air-passages,  and  so  likely  to  cause  special  dangers  under  an  anaesthetic  ; 
of  the  severity  of  the  operation,  its  duration,  and  the  degree  of  trauma  it 
necessitated  ;  of  the  condition  of  the  patient  as  regards  resistive  power  ;  or  of 
the  presence  of  intercurrent  toxaemia,  asphyxia,  shock,  and  so  on. 

The  only  exact  method  of  arriving  at  the  incidence  of  danger  of  anaesthetics 
is  by  experiment,  but  here  again  this  plan  supplies  less  information  than  we  need 
in  the  present  investigation.  It  tells  us  that  any  given  anaesthetic,  or  succession 
or  mixture  of  anaesthetics,  acting  under  known  conditions  of  time  and  circum- 
stance, upon  normal  individuals,  will  produce  certain  results.  We  can  estimate 
the  progressive  effects  of  increased  concentration,  or  of  hmitation  of  oxygen  or 
of  carbon  dioxide  :  but  although  we  can  crudely  reproduce  a  few  pathological 
conditions,  we  cannot  with  certainty  learn  by  this  means  what  are  the  effects 
of  the  interaction  of  either  anaesthetics   or  analgesics   upon   diseased  tissues. 


ANMSTHETICS  21 

The  perversion  of  the  nerve-controls  existent  in  cases  of  exophthalmic  goitre  ; 
the  congeries  of  conditions  grouped  under  the  term  lymphatism  ;  those  conditions 
which  underlie  the  state  called  delayed  chloroform  poisoning  :  these  are  incapable 
of  experimental  reproduction  in  a  form  which  would  enable  us  to  estimate  the 
incidence  of  danger  when  anaesthetics  are  in  use  in  their  presence. 

We  must,  however,  consider  as  the  first  step  in  arriving  at  a  prognosis  in 
any  type  of  patient  under  any  anaesthetic,  the  accepted  physiological  behaviour 
of  the  anaesthetic  towards  normal  individuals  ;  and  next,  since  pathological 
states  are  but  variants  from  the  physiological,  we  can  deduce  the  probable 
effect  of  any  given  anaesthetic  when  acting  upon  a  patient  with  a  known  morbid 
lesion.  For  example  :  we  know  that  nitrous  oxide  gas  lowers  the  actual  oxygen 
content  of  the  blood,  and  hence  of  the  tissues  ;  further,  that  at  a  point  this 
declension  will  produce  tissue-asphyxia.  Now,  if  the  patient's  pathological 
lesion  has,  by  its  effects,  already  lowered  the  oxygen  content  of  the  tissues, 
the  administration  of  nitrous  oxide  gas  is  probably  contra-indicated  ;  or  if  this 
anaesthetic  is  employed,  we  should  look  for  a  much  speedier  superinduction 
of  asphyxia  than  in  the  normal  person.  In  this  case  the  choice  of  the  method 
would  come  to  our  aid  ;  for  by  employing  an  appropriate  mixture  of  this 
anaesthetic  with  oxygen,  the  danger  in  certain  cases  would  be  obviated.  Thus 
we  see  that  we  cannot  separate  the  anaesthetic  itself  from  the  method  of  its 
employment,  if  we  are  to  arrive  at  a  precise  prognosis  or  incidence  of  danger 
in  any  given  type  of  cases. 

A  further  difficulty  is  encountered  in  our  inquiry  when  we  pass  from  the 
type  of  patients  to  any  individual  member  of  the  group.  Although  he  may 
conform  to  the  peculiarities  of  the  group,  yet  he  will  in  very  many  cases  reveal 
some  departure  from  these  which  is  apt  to  invalidate  any  general  statement 
as  to  his  immunity  from  danger.  We  have  to  deal  with  two  entities,  the  conscious 
and  the  anaesthetized  ;  and  since  the  bridging  over  the  passage  between 
perceptive  senscience  and  anaesthesia — the  period  of  induction — is  the  acme 
of  the  curve  of  danger  in  any  form  of  anaesthesia,  we  are  compelled  to  study 
the  psychological  reaction  of  the  patient  towards  the  anaesthetic,  as  well  as  the 
physiological  reaction  of  the  drug  towards  the  patient.  It  is  the  danger  of 
fear-shock,  which  in  pre-anaesthetic  days — as  indeed  at  the  present  day — 
occasionally  proved  fatal,  which  becomes  most  formidable  when  we  have  to 
decide  between  the  use  of  an  anaesthetic  which  abolishes  consciousness,  and  an 
analgesic,  whether  local  or  spinal,  which  prevents  perception  of  pain,  but  fails 
to  remove  the  fear  lest  pain  will  come.  While  some  persons  experience  no 
such  dread,  others  faint  even  though  no  actual  pain  from  trauma  has  occurred. 

The  problem  before  us  has  to  be  studied  from  yet  a  further  aspect.  The 
dangers  connected  with  either  anaesthesia  or  analgesia  are  not  ended  when 
the  operation  has  been  completed.  The  after-effects,  mental  and  bodily,  may 
either  prejudice  convalescence,  or  produce  actual  and  grave  pathological  condi- 
tions such  as  mania,  or  pulmonary,  renal,  or  hepatic  lesions  ;  and  these  may 
ultimately  prove  fatal. 

Having  considered  these  general  aspects  of  the  subject,  it  remains  to  discuss 
those  factors  which  we  have  shown  to  make  for  the  incidence  of  danger  or  its 
avoidance,  to  indicate  how  far  these  dangers  can  be  foreseen,  and  bj'  what 
means  they  can  be  best  prevented  or  mitigated. 

The  factors  making  for  safety  or  danger  during  anaesthesia  or  analgesia  are  : 

1.  The  (a)  anesthetic  or  {b)  analgesic  itself. 

2.  The  method  of  employment. 

3.  The  experience  and  knowledge  of  the  person  giving  the  drug. 

4.  The  condition  of  the  patient. 


INDEX     OF    PROGNOSIS 


5.  The  nature  and  duration  of  the  operation,  and  the  intercurrent  conditions 
such  as  trauma,  and  the  shock  arising  as  a  result  thereof. 

6.  Post-operative  effects. 

I.  a.  Ansesthetics. — The  chemical  and  physical  properties  of  the  known 
anaesthetics  determine  the  following  law  as  regards  their  safety  or  the  reverse : 
All  drugs  containing  one  of  the  haloid  elements — chlorine,  bromine,  iodine — 
being  protoplasm  poisons  are  more  dangerous  than  those  in  which  the 
haloid  is  replaced  by  oxygen.  The  danger  increases  directly  with  the  amount 
of  the  chlorine,  etc.,  present.  The  lower  the  boihng-point  and  the  greater 
the  specific  gravity  of  the  hquid,  the  greater  the  danger.  The  gaseous  anaes- 
thetic is  safer  than  the  liquid,  and  the  liquid  than  the  solid — a  law  which  follows 
from  the  preceding  one  asserting  the  greater  safety  of  the  highly  volatile  over 
the  less  volatile  drug. 

Hence  we  should  expect  that  the  order  of  safety  of  the  commoner  anassthetics 
would  be  as  follows  :  nitrous  oxide  ;  ether  ;  ethyl  chloride  ;  chloroform  ; 
ethyl  bromide.  CUnically,  we  find  that  for  normal  subjects  this  order  is  correct  ; 
while,  experimentally,  we  obtain  practically  identical  results.  Treated  statisti- 
cally, the  incidence  of  death  is  :  chloroform,  i  in  3000  ;  ethyl  chloride,  i  in 
13,000  ;  ether,  i  in  23,000  ;  nitrous  oxide,  i  in  200,000  ;  raixtures  of  nitrous 
oxide  and  oxygen,  uncertain,  but  a  very  low  rate  prevails.  These  figures,  however, 
cannot  be  accepted  as  being  more  than  rough  approximations.  In  the  case  of 
ethyl  chloride  the  estimate  given  is  probably  much  too  favourable  to  that 
anaesthetic. 

Waller's  experiments  concerning  the  effect  of  chloroform  and  of  ether  upon 
nerve  tissue  led  him  to  believe  that  the  former  was  seven  times  more  dangerous. 
This  is  important,  as  deaths  due  to  ansesthetics,  when  they  arise  from  overdosage 
— as  opposed  to  what  may  be  called  mechanical  conditions — are  brought  about 
mainly  through  the  poisoning  of  the  centres  in  the  medulla  oblongata.  But, 
as  has  been  pointed  out  above,  the  incidence  of  death  is  largely  dependent 
upon  the  condition  of  the  patient  being  such  as  to  be  adversely  affected  by 
particular  anaesthetics  ;  and  so  it  is  necessary  to  consider  briefly  what  are  the 
distinguishing  actions  of  the  commoner  ansesthetics,  and  their  bearing  upon 
pathological  lesions  of  the  systems  concerned  with  the  processes  of  life. 

Chloroform  produces  haemolysis— as  does  ethyl  chloride  in  a  less  degree  ;  chloro- 
form also  diminishes  the  activity  of  glandular  epithelium,  and  ultimately  acts  as 
a  protoplasm  poison,  destroying  tissue  Ufe.  Its  effects  upon  the  tissues  vary 
directly  with  the  nature  of  the  latter  ;  thus,  nervous  tissues  suffer  most,  the 
heart  muscle  more  than  the  voluntary,  and  the  voluntary  muscles  more  than 
the  involuntary ;  the  hver  is  the  most  vulnerable  of  the  viscera,  then  the 
kidneys.  This  is,  perhaps,  best  understood  by  stating  that  if  the  various  tissues 
are  subjected  to  chloroform-containing  fluids,  the  percentage  strength  required, 
firstly  to  inhibit  function,  and  ultimately  to  destroy  the  tissues'  power  of 
functionating,  is  lowest  in  the  case  of  the  highly-organized  tissues  such  as  nerve 
cells  and  fibres,  while  in  the  case  of  other  tissues,  higher  and  higher  strengths 
or  percentage  values  have  to  be  used  to  inhibit  or  destroy.  The  elimination 
of  chloroform  is  comparatively  slow,  and  any  interference  with  the  functional 
activity  of  the  usual  emunctaries,  such  as  progressively  occurs  as  chloroform 
inhibits  their  action  more  and  more,  tends  to  the  accumulation  of  the  anaesthetic, 
and  its  storing  up  in  the  tissues,  with  disastrous  effects.  When,  however,  care 
is  taken  to  avoid  such  a  strength  of  vapour  as  produces  this  inhibition  of  tissue 
function,  this  danger  is  avoided. 

Ethyl  chloride  and  ethyl  bromide,  so  far  as  we  know,  behave  similarly ;    but 


ANESTHETICS 


23 


as  they  are  seldom  employed  for  any  but  brief  periods,  little  is  definitely  known 
of  their  prolonged  effects. 

Ether  causes  haemolysis,  but  unless  asphyxial  complications  are  permitted, 
its  effect  is  slight  in  this  direction.  It  stimulates  all  the  cells  except  those 
concerned  in  the  urinary  function.  The  secretions  of  the  mouth  and  respiratory 
tract  are  markedly  increased.  In  the  amounts  employed  in  anaesthesia,  it 
produces  at  first  excitation  of  function,  and  then  inhibition,  but  not  destruction, 
of  the  protoplasm.  Hence,  if  the  inhibition  is  permitted  to  extend  to  a  dangerous 
degree,  the  tissues  recover  their  power  of  function  when  favourable  conditions 
are  re-established.  Ether  acts  powerfully  upon  bacteria.  It  possesses  a  great 
avidity  for  fatty  material,  and  so  it  is  believed,  upon  experimental  evidence, 
tends  to  destroy  phagocytes  by  damaging  their  essential  fatty  environment  ; 
hence  phagocytosis  is  lessened  or  destroyed  until  the  ether  is  eliminated  and  the 
phagocytes  are  able  to  re-assert  their  function.  Owing  to  its  ready  volatihzation, 
ether  rapidly  dissociates  itself  from  the  tissues  ;  its  elimination  requires  con- 
siderable absorption  of  heat,  and  hence  it  occasions  a  fall  of  body  temperature. 
It  certainly  causes  some  tissue  irritation,  revealing  itself  in  catarrhal  conditions  ; 
especially  is  this  so  in  the  case  of  the  lungs  and  kidneys.  The  extent  of  this 
action,  so  far  as  the  renal  structures  are  concerned,  was  investigated  by  me 
with  the  aid  of  Dr.  Goodman  Levy,  and  the  conclusion  at  which  we  arrived 
was  that,  provided  the  amount  of  ether  perfusing  the  renal  vessels  was  not 
excessive,  interference  with  function  was  slight.  The  comparison  of  chloroform 
and  ether  in  this  connection  is  valuable.  The  former  anaesthetic  is  less  prone 
to  initiate  albuminuria,  although  more  apt  to  increase  its  amount  if  pre-existing. 
Ultimately,  chloroform  tends  to  cause  necrobiosis  of  renal  epithelium,  while 
ether  does  not  ;  though  it  must  be  admitted  that  this  deleterious  result  only 
follows  excessive  quantities  of  the  former  anaesthetic. 

Nitrous  oxide  resembles  ether  in  its  stimulating  action  upon  cells.  This  is 
followed  by  inhibition  of  function.  It  unquestionably  possesses  a  specific 
action,  and  does  not  superinduce  unconsciousness  either  by  depriving  the  tissues 
of  oxygen,  or  by  splitting  up  and  causing  superoxidation  (apnoea).  As  to  some 
extent  it  replaces  oxygen  in  the  haemoglobin  of  the  erythrocytes,  and  probably 
in  the  fixed  cells,  its  effect  is  commonly  associated  with  a  superadded  asphyxial 
effect.  This,  however,  is  concomitant  rather  than  essential,  so  that  when  it  is 
obviated,  the  power  of  nitrous  oxide  to  induce  insenscience  is  in  no  way  hindered. 

Mixtures  of  ancBsthetics,  such  as  the  A.C.  (i  volume  of  alcohol  to  9  of  chloro- 
form), the  C.E.  (2  of  chloroform  to  3  of  ether*),  and  the  A.C.E.  (i  of  alcohol,  2 
of  chloroform,  and  3  of  ether),  act  variously  and  variedly  according  as  they  are 
administered  by  one  method  or  another.  In  hot  weather,  chloroform  and  ether 
mixtures  given  by  an  open  method  produce  mainly  an  ether  effect  at  first, 
and  later  a  chloroform  effect.  A  closed  or  semi-closed  method  promotes  a 
chloroform  effect,  modified  by  the  dilution  due  to  the  other  ingredients  of  the 
mixture.  It  is  not  safe  to  assume  that  true  antagonism  exists  in  such  mixtures, 
since  the  component  anaesthetics  evaporate  individually  and  at  different 
temperatures.  Further,  they  possess  a  various  coefficient  of  '  spread  '  when 
sprinkled  upon  an  absorbent  surface  such  as  lint  or  gauze,  and  the  rate  of  evapora- 
tion may  be  taken  roughly  as  varying  directly  as  the  spread  and  inversely  as 
the  wetting  ;  while  the  heavier  vapours  sink  towards  the  reclining  patient, 
the    lighter    rise  and    escape    into   the    atmosphere    of    the    room.     Schafer, 

*  There  are  several  varieties  of  this  mixture  in  use  besides  that  named.  For  example  :  I  volume 
of  chloroform  to  2  of  ether  ;  equal  volumes  of  chlorcform  and  ether ;  i  volume  of  chloroform  to 
4  of  ether. 


24  INDEX     OF    PROGNOSIS 

however,  has  demonstrated  that  the  alcohol-chloroform  mixture  is,  in  fact, 
more  stable,  so  that  a  certain  amount  of  antagonism  is  existent.  This  was 
assumed  in  the  case  of  the  A.C.E.  mixture  also,  and  is  probably  true,  though 
to  a  less  extent,  although  the  ether  component  acts  as  a  diluent,  not  as  an 
antagonist,  to  the  chloroform.  It  will  be  observed  that  when  alcohol,  ether, 
and  chloroform  are  shaken  together,  heat  is  generated,  a  fact  which  appears 
to  indicate  a  more  intimate  association  than  exists  in  simple  solutions. 

The  employment  of  mixtures  of  the  vapours  themselves,  by  some  method 
such  as  that  suggested  by  Gwathmey,  removes  many  of  these  objections. 
Such  elaborations  as  those  of  Schleich's  or  Wertheim's  solutions  are  too  infre- 
quently employed  to  need  analysis. 

Gaseous  mixtures,  such  as  that  of  nitrous  oxide  and  air  or  oxygen,  fall  into 
another  category.  Here  the  oxygen  or  air  merely  supplies  the  necessary  aeration 
and  so  obviates  tissue  asphyxia,  hence  permitting  of  the  extensive  employment 
of  nitrous  oxide  gas.  The  hyperpnoea  commonly  existent  with  the  methods 
in  use  lessens  the  carbon  dioxide  content  of  the  blood,  leading  to  acapnic  condi- 
tions ;  so  that  the  addition  of  carbon  dioxide  gas  to  the  nitrous  oxide-oxygen 
mixture  finds  favour  with  some  persons,  and  is  employed  for  prolonged  opera- 
tions. The  simplest  method  of  supplying  carbon  dioxide  is  by  allowing  partial 
re-breathing,  and  this  is  provided  for  by  Teter  and  others  in  their  apparatus 
for  prolonged  administration  of  these  gases  for  the  purposes  of  major  surgery. 

Such  combinations  as  amyl  nitrite  and  chloroform,  somnoform  (ethyl  chloride, 
methyl  chloride,  and  ethyl  bromide),  and  ethyloform,  a  more  dangerous  variant 
of  the  last,  need  merely  to  be  mentioned  as  extremely  unsatisfactory  agents. 

We  now  come  to  the  employment  of  alkaloidal  bodies  in  association  with 
general  anaesthetics.  Those  most  commonly  in  use  are  atropine,  morphine, 
scopolamine,  omnopon,  strychnine.  We  may  add  chlor-butyl,  although  it  is 
not  alkaloidal. 

Atropine. — The  use  of  this  drug,  gr.  j^.  given  hypodermically  one  hour 
before  inhaling  an  anassthetic,  has  revolutionized  the  methods  of  etherization. 
Its  action  checks  the  excessive  secretion  of  the  buccal  and  respiratory  areas, 
and  so  removes  one  of  the  great  drawbacks  of  ether.  The  dose  has  to  be  varied 
according  to  circumstances.  In  some  persons,  persistent  throat  dryness  follows 
its  use.  Children,  as  a  rule,  tolerate  atropine  well.  A  further  advantage  of 
atropine  is  that  it  lessens  the  irritabihty  of  the  pneumogastric  nerves,  and  so 
minimizes  the  danger  of  vagal  inhibition  of  the  heart  under  chloroform. 
Hoelscher's  observations  appear  to  prove  that  much  of  the  post-anaesthetic 
chest  trouble  is  due  to  the  aspiration  into  the  air-passages  of  sahva  and 
mucus  impregnated  with  the  anaesthetic  ;  hence,  lessening  this  secretion 
by  atropine  diminishes  the  risk  ;  further,  since  swallowing  the  mucus  mixed 
with  condensation  of  the  vapour  of  the  anaesthetic  promotes  a  catarrhal 
condition  of  the  stomach  and  causes  vomiting,  atropine  lessens  sickness. 
Although  atropine  materially  lessens  the  nausea  and  vomiting  due  to  the 
anaesthetic,  it  fails  in  a  few  cases,  especially  if  sepsis  is  present. 

Morphine,  scopolamine. — There  is  no  question  that  although  morphine  and 
atropine  are  commonly  employed  together,  these  drugs  act  better  and  more  safely 
when  combined  with  scopolamine.  The  pharmacological  law  which  recognizes 
that  several  drugs  exert  synergic  action  in  some  directions,  while  they  antagonize 
in  others,  holds  with  regard  to  these  alkaloids.  Thus  the  respiratory  centre 
which  is  depressed  by  morphine  is  stimulated  by  the  atropine  bodies  ;  while 
scopolamine  acts  concurrently  with  morphine  in  producing  suspension  of  the 
consciousness.  Scopolamine  is  a  dangerous  drug  when  used  by  itself ;  its 
undesirable  qualities  are  lessened  or  removed,  however,  when  it  is  associated 


ANESTHETICS  25 

with  morphine  and  atropine.  The  outstanding  advantages  of  these  drugs 
are  :  that  they  soothe  the  mental  fear  of  the  patient,  and  they  lessen  the  amount 
of  the  general  anaesthetic  required.  The  disadvantages  are  that  they  disguise, 
to  some  extent,  the  guides  to  anaesthesia  by  interfering  with  pupillary  phenomena  ; 
they  prolong  induction,  as  the  breathing  is  more  shallow,  and  the  thoracic 
excursions  are  diminished ;  they  induce  a  prolonged  and  profound  sleep 
consecutive  to  the  operation  which,  although  highly  beneficial  to  the  patient, 
requires  special  and  heedful  watching,  lest  malposition  of  the  head,  falling  back 
of  the  tongue,  trickling  of  blood  into,  or  accumulation  of  mucus  about,  the 
glottis,  lead  to  interference  with  respiration.  Their  use  presupposes  that  the 
patient  has  been  carefully  examined  to  ascertain  if  there  is  any  contra-indication 
to  the  use  of  morphine.  In  local  or  spinal  analgesia,  the  use  of  these  drugs  is 
obviously  beneficial  ;  but  it  needs  caution  in  the  case  of  thecal  injection,  lest 
the  action  of  the  stovaine  or  novocain,  travelling  somewhat  high,  should 
interfere  with  the  medullary  centres  already  drugged  by  the  morphine  which 
has  been  injected. 

Omnopon. — The  difficulty  of  standardizing  the  preparations  of  morphine 
has  led  to  the  adoption  of  a  mixture  of  opium  alkaloids  with  a  morphine  action, 
under  the  name  of  omnopon  (pantopon) .  Dr.  Sahli  has  shown  that  the  chlorides 
of  these  alkaloids  are  capable  of  being  standardized,  and  so  a  definite  dose  with 
a  known  morphine  effect  can,  it  is  asserted,  be  obtained.  This  substance  is 
employed,  in  a  similar  way  to  morphine,  in  association  with  other  alkaloids. 

The  dangers  of  ether  in  the  direction  of  pulmonary  and  renal  sequelae,  and  those 
of  chloroform  in  that  of  cardiac  enfeeblement,  are  diminished  by  using  these 
alkaloids  adjuvantly;  and  this  is  markedly  so  in  the  case  of  irritable  heart 
conditions,  such  as  different  forms  of  tachycardia.  The  use  of  these  alkaloids 
would  increase  the  danger  in  all  states  in  which  the  respiratory  system  is 
hampered,  either  through  cerebral  or  circulatory  causes.  Hence,  in  operations 
upon  the  brain  or  spinal  cord  if  chloroform  is  to  be  used,  also  in  cases  in  which 
cyanosis  or  breathlessness  is  present — unless  when  the  latter  is  due  to  cardiac 
instability — their  use  is  detrimental. 

Strychnine  is  given  hypodermically  just  before  an  anaesthetic,  with  the  view 
of  antidoting  chloroform,  but  it  does  not  accomplish  this  object ;  indeed  it  is 
probably  detrimental,  and  when  associated  with  morphine  produces  little  if  any 
beneficial  effect,  although  it  prolongs  induction,  and  causes  the  muscular  rigidity 
of  the  patient  to  be  emphasized.  If  strychnine  is  of  any  value  in  the  small  doses 
usually  adopted,  it  is  only  in  the  direction  of  stimulating  the  respiration. 

Chlor-butyl. — Chlor-butyl  (gr.  xv.),  given  ninety  minutes  before  the  anaes- 
thetic, determines  drowsiness,  and  certainly  diminishes  the  risk  of  after- 
sickness. 

b.  Analgesics. — The  dangers  of  cocaine,  both  in  endermic  injection,  intra- 
thecal injection,  and  when  introduced  into  the  urethra,  are  so  well  known  that 
most  persons  have  relinquished  its  use. 

Novocain  is  probably  the  safest  drug  for  local  and  regional  analgesia,  if 
properly  sterilized  and  employed  with  the  addition  of  adrenine. 

Stovaine  seems  less  employed  in  local  analgesia,  owing  to  its  damaging  effect 
on  the  tissues  ;  but  it  is  certainly  one  of  the  safest  of  the  drugs  used  in  intra- 
thecal injection.  It  produces  some  haemolysis,  and  its  use  is  not  free  from  the 
liabihty  of  being  followed  by  oculomotor  paralysis. 

Tropacocaine  and  alypin  have  their  advocates,  but  probably  neither  is  as  safe 
as  stovaine  for  spinal  analgesia.  The  question  of  combining  these  drugs  with 
adrenine  is  discussed  under  another  caption   (see  Methods  of  Employment). 

The  prognosis  as  to  danger  in  the  use  of  local  and  spinal  analgesia  is  extremely 


26 


INDEX    OF    PROGNOSIS 


difficult  to  estimate,  as  so  much  depends  upon  the  method  employed  and  the 
condition  of  the  patient,  and  these  are  variants  in  all  cases.  This  fact  renders 
generalization  of  no  practical  value.  We  know,  however,  that  these  methods, 
especially  the  intrathecal  injection  of  drugs,  have  inherent  sources  of  danger, 
since  when  the  analgesic  has  once  entered  the  tissues  it  is  impossible  to  abrogate 
its  action.  Slight  errors  in  technique  also  matter  more  in  such  procedures 
than  in  inhalational  methods.  Assumiing  experience,  absolute  asepsis,  and 
careful  regulation  of  the  dose,  the  danger  to  life  is  probably  slight  in  the  hands 
of  experts,  and  the  sequelae  are  not  necessarily  serious.  It  is,  however,  impos- 
sible, in  the  present  state  of  our  knowledge,  to  promise  total  immunity  from 
them,  or  to  forecast  the  degree  of  their  severity. 

Statistically,    the    death-rate   under   spinal    analgesia   is    given    by   various 
authorities  as  follows  : — 

Mortality    of    Spinal    Analgesia. 


Reporter 

Cases 

Deaths 

Hahn      -           -           -           - 

Patterson 

Reclus    - 

Zahradnickj^ 

Wainwright 

Strauss  - 

708 

7807 

2000 

4679 

16300 

22717 

8 

20 
6 

12 
14 
46 

Total 

54211 

106 

This  gives,  roughly,  a  mortality  of  i  in  500.  Too  much  importance  must 
not  be  attached  to  such  figures,  as  many  of  the  continental  surgeons  state  that 
they  have  used  the  method  in  thousands  of  cases  without  a  death.  The  same 
caution  applies  to  statistics  of  deaths  under  general  anaesthetics.  If  we  accept 
a  recent  estimate  from  the  United  States,  we  have — chloroform,  i  death  in 
2,500  cases ;  ether,  i  in  16,000 ;  nitrous  oxide,  i  in  200,000.  But  many 
specialists  have  employed  these  anaesthetics  without  a  single  death. 

A  study  of  the  elaborate  tables  and  precis  of  fatalities  issued  by  the  British 
Medical  Association  in  1900*  shows  that  comparatively  few  of  the  deaths, 
recorded  with  sufficient  precision  to  admit  of  exact  classification,  are  due  wholly 
and  solely  to  the  anaesthetic.  The  factors  adopted  by  the  workers  on  this 
committee  were — the  anaesthetic,  the  operation,  and  the  state  of  the  patient  at 
the  time  of  the  operation.  Although  the  number  of  cases  examined  was  com- 
paratively small,  25,920,  yet  it  is  sufficiently  large  to  form,  a  fair  basis  for 
comparison.  However,  the  last  two  factors,  the  operation  and  the  state  of  the 
patient,  which  may  at  first  sight  appear  to  be  constants,  are  in  fact  not  so.  This 
is  shown  by  the  consideration  that,  for  patients  whose  bodily  state  is  extremely 
unfavourable,  the  '  safest  '  anaesthetics  are  relied  upon  ;  so  that  these  agents 
are  employed  under  desperate  circumstances,  with  results  which  give  for  such 
anaesthetics  a  less  favourable  incidence  of  fatality.  A  further  point  which  has 
to  be  taken  into  consideration,  when  comparing  the  results  of  general  anaesthesia 
with  spinal  and  local  analgesia,  is  that  whereas  the  statistics  of  the  first  comprise 
every  type  of  administrator,  including  many  who  are  quite  inexperienced  and 


Report  of  the  Anaesthetics  Committee  appointed  1S91. 


ANESTHETICS 


27 


even  devoid  of  medical  knowledge,  the  second  gives  the  work  of  keen  experts 
whose  care  and  acumen  are  unquestionable  and  whose  technique  is  as  good  as 
our  present  knowledge  of  analgesia  permits  ;  nor  is  this  knowledge  slight,  since 
the  stage  of  experimental  groping  has  passed,  and  methods  and  technique  are 
practically  settled. 

Opinions,  again,  are  in  absolute  conflict  about  what  pathological  conditions 
contra-indicate  the  spinal  method.  It  may  be  useful  to  indicate  briefly  the 
consensus  of  views.  The  method  is  recommended  in  acute  abdominal  con- 
ditions, for  operations  below  the  umbilicus,  especially  in  '  acute  appendix  ' 
cases  ;  also  when  acute  or  serious  bronchial  or  pulmonary  disease  exists  and 
the  lungs  are  waterlogged  ;  and  in  severe  glycosuria,  and  gangrene  of  the 
extremities. 

Whether  patients  with  serious  cardiac  lesions,  with  excessive  blood-pressure, 
or  with  pronounced  albuminuria,  should  have  the  spinal  method  is  very  doubtful. 
The  decision  could  only  be  made  by  scrutiny  of  each  case.  Whereas,  formerly, 
the  old  and  feeble,  suffering  from  serious  abdominal  trouble,  were  regarded 
as  good  subjects  for  spinal  methods,  this  view  is  not  at  present  universally  held. 
In  cases  of  intestinal  obstruction  complicated  with  stercoraceous  vomiting, 
the  spinal  method  was  looked  to  as  a  way  out  of  a  dangerous  impasse.  Un- 
happily, several  deaths  have  occurred  through  faecal  drowning  when  spinal 
analgesia  was  obtained,  the  features  of  which  were  identical  with  those  occasion- 
ally met  with  when  general  anaesthesia  was  adopted.  When  feasible,  local 
analgesia  is  undoubtedly  safer  than  is  the  spinal  method  for  such  patients,  but 
it  fails  to  remove  the  distress  arising  from  handling  the  viscera. 

If  the  dangers  of  sepsis  are  omitted,  local  analgesia  offers  few  disqualifica- 
tions, except  that  it  is  only  applicable  in  comparatively  few  cases,  unless  we 
are  willing  to  inflict  a  certain  amount  of  pain,  pain  which  is  sometimes  severe.  Its 
best  use  is  undoubtedly  when  combined  with  light  narcosis,  whether  by  alkaloids 
or  inhalation.  It  must  be  remembered  that  persons  who  were  subjects  of  the 
status  lymphaticus  have  died  under  the  method,  even  though  no  overdose  had 
been  given.  Another  danger  which  is  not  always  recognized  is  that  nervous 
persons,  and  those  whose  mentality  is  unstable,  are  liable  not  only  to  serious 
neurasthenia,  but  even  to  delusional  mania,  as  sequelae  of  a  trivial  operation 
performed  under  local  analgesia.  Also  after-pain  is  stated  to  be  more  severe 
when  local  analgesia  has  been  employed. 

To  sum  up  :  in  serious  conditions  it  is  best  to  restrict  spinal  analgesia  to 
patients  who  are  not  good  subjects  for  the  methods  of  general  anaesthesia, 
unless  the  greater  facility  of  obtaining  muscular  relaxation  by  the  former 
method  gives  the  surgeon  a  better  chance  of  performing  an  operation  in  the 
success  of  which  the  patient's  life  is  involved.  Local  analgesia,  unless  by  regional 
methods,  is  dangerous  in  septic  cases  ;  it  is  valuable  for  small  and  superficial 
operations ;  its  success  in  exophthalmic  goitre  is  at  least  doubtful,  unless 
associated  with  a  general  anaesthetic. 

2.  Methods  of  Employment. — Since  the  dangers  arise  from  overdosage,  or 
from  using  an  anaesthetic  by  some  method  which  embarrasses  the  circulation, 
respiration,  nerve  controls,  or  metabolism  of  a  patient  already  suffering  from 
disease  of  one  or  other  of  these  systems,  the  method  selected  makes  for  safety 
if  it  gives  the  administrator  absolute  control  of  the  dosage  of  the  anscsthetic,  or 
for  danger  if  it  fails  in  this  regard  and  further  imposes  upon  the  patient  an 
increased  disability.  Hence,  dosimetric  methods  of  giving  chloroform,  always 
desirable,  are  essential  in  operations  upon  persons  with  feeble  circulation  (cardiac 
disability),  in  cases  of  goitre  or  lymphatism,  and  in  operations  upon  the  cen- 
tral  nervous   system. 


28  INDEX     OF    PROGNOSIS 

SufEocative  conditions  contra-indicate  the  employment  of  ether  or  nitrous 
oxide,  since  these  anaesthetics  provoke  venous  engorgement  of  the  air-passages, 
as  well  as  the  adoption  of  closed  methods. 

Posture  becomes  an  integral  part  of  the  method  in  operations  upon  the 
thorax  when  an  abscess  cavity  opens  into  a  bronchus,  since  turning  a  patient 
upon  his  sound  side  may  lead  to  filling  his  unaffected  lung  with  fluid. 

Open  ether  methods  are  at  the  present  time  regarded  as  peculiarly  safe ; 
but  if  used  without  atropine,  they  promote  excessive  secretion,  and  are  apt 
to  bring  about  excessive  stimulation,  which  in  its  turn  leads  to  exhaustion  of 
the  nerve  centres  and  finally  to  collapse. 

Infusion  methods  (ether),  while  of  great  value  in  prolonged  exhausting  opera- 
tions and  in  cases  of  profound  blood-loss,  are  liable  to  cause  cedema  if  excessive 
quantities  of  saline  are  allowed  to  enter  the  circulation. 

Hedonal,  when  infused,  unless  in  cranial  surgery,  is  dangerous,  sincfe  the  effect 
persists  for  hours,  and  patients  may  die  before  the  drug  is  eliminated  ;  they 
incur  special  risks  from  malposition  in  bed,  and  from  even  slight  haemorrhage, 
since  the  blood  may  pass  into  the  air-passages.  Such  dangers  are  peculiarly 
apt  to  arise  in  all  operations  upon  the  mouth,  nose,  and  upper  air-passages.  In 
these  cases,  whether  chloroform,  infusion  of  ether  or  hedonal,  or  colonic  etheriza- 
tion is  adopted,  the  method  used  must  enable  the  patient  to  retain  his  larj^ngeal 
reflex,  otherwise  foreign  material  will  invade  the  lungs.  It  is  urged  in  favour 
of  the  insufflation  and  pharyngeal  methods,  that  such  an  accident  is  impossible  ; 
and  were  the  technique  of  these  plans  less  difficult,  there  is  no  doubt  that  one 
or  the  other  would  give  the  patient  the  best  chance  of  avoiding  these  accidents. 

Although  maintaining  a  high  level  of  safety,  the  method  of  prolonged  nitrous 
oxide  administration,  with  or  writhout  oxygen,  whether  by  the  nasal  route  or  by 
the  apparatus  of  Teter  or  Boothby,  is  less  safe  than  when  employed  for  one  brief 
inhalation.  A  severe  strain  is  imposed  upon  the  respiration  ;  and  the  heart  and 
blood-vessels,  unless  healthy,  are  overtaxed  as  the  blood-pressure  becomes  raised. 

Intratracheal  insufflation,  so  far  as  we  know  at  present,  presents  great  possi- 
bilities of  good  ;  but  even  sUght  errors  of  technique  may  cause  serious  inter- 
ference with  the  pulmonary  circulation  through  prolonged  plus  pressure  being 
maintained  in  the  lungs,  although  obviously  this  is  not  a  necessity  of  the  method. 

The  methods  of  colonic  etherization  are  valuable,  both  for  operations  on  the 
air-passages  and  on  the  thorax,  lungs,  and  pleura.  They  prove  most  dangerous 
unless  the  air-ways  are  kept  patent,  and  also  when  the  colon  has  been  weakened 
by  disease,  and  especially  if  ulceration  has  existed.  If  liquid  ether  enters  the 
bowel,  serious  proctitis  will  ensue;  and  excessive  injection  of  the  vapour  has 
caused  meteorism,  and  even  rupture  of  the  bowel.  The  ether  (75  per  cent)  in 
oil  method  of  Gwathmey  is  yet  on  its  trial ;  it  has  been  recently  shown  to  be  less 
free  from  danger  than  was  originally  supposed.  Patients  at  times  remain 
unconscious  for  many  hours,  nor  has  it  been  free  from  fatalities. 

The  danger  of  intermittent  a-dosimetric  methods  in  the  use  of  chloroform 
has  long  been  recognized,  but  recent  work  has  shown  that  unless  complete 
anaesthesia  is  induced,  cardiac  fibrillation  is  produced.  Yandell  Henderson 
believes  the  condition  is  really  due  to  acapnia  ;  but  whatever  theory  we  adopt 
to  explain  the  phenomena,  there  is  no  doubt  that  methods  which  bring  about  this 
condition  are  fraught  with  grave  danger  to  the  patient.  However,  chloroform 
given  by  a  dosimetric  system  is  certainly  safer  than  when  an  open  method  is 
employed.  The  depth  of  narcosis  can  be  controlled  by  dosimetrj^  since  it  is 
as  easy  to  employ  a  high  as  a  low  percentage  value  of  vapour.  If  experts  restrict 
the  strength  to  values  of  2  per  cent  or  less,  it  is  because  evidence  exists  which 
proves  these  values  are  the  safest. 


ANESTHETICS  29 


With  regard  to  the  methods  of  giving  ethyl  chloride,  it  may  be  said  that  the 
open  plan  much  used  by  Hornibrook  in  Melbourne  is  reputed  safer  than  closed 
methods.  Prolonged  use  of  this  anaesthetic  presents  much  the  same  dangers 
as  does  chloroform,  unless  careful  dosage  is  adopted. 

Spinal  and  Local  Analgesia. — Broadly  speaking,  injection  above  the  lumbar 
region  is  far  more  dangerous  than  at  the  place  of  election  between  the  spines  of 
the  second  and  third,  or  third  and  fourth,  lumbar  vertebrae.  Experience  points 
to  the  danger  of  the  method  being  increased  if  adrenine  is  combined  with  the 
analgesic,  and  to  the  absence  of  any  commensurate  benefit  from  prolongation 
of  the  period  of  insensibility  to  pain. 

In  local  or  regional  analgesia,  on  the  other  hand,  adrenine  together  with  novo- 
cain lessens  the  dangers,  provided  the  quantity  of  adrenine  is  strictly  limited. 
That  adrenine  is  a  dangerous  drug  has  been  shown  by  Goodman  Levy  and 
others,  especially  when  used  in  conjunction  with  cocaine  in  nasal  surgery.  This 
is  peculiarly  the  case  when  chloroform  is  also  used  and  light  narcosis  is  main- 
tained ;  cardiac  fibrillation  appears  to  occur,  with  a  fatal  result. 

3.  The  Administrator. — This  factor  has  been  already  dealt  with  in  the  first  part 
of  the  article. 

4.  The  Physical  and  Mental  State  of  the  Patient. — 

Extremes  of  Life. — The  rule  of  giving  chloroform  to  persons  up  to  six  years  of 
age  and  to  those  over  sixty  is  a  survival  of  the  myth  that  children  and 
women  in  labour  enjoy  immunity  from  danger  from  that  anaesthetic.  As  a 
matter  of  fact,  children  are  peculiarly  liable  to  danger,  owing  to  their  proneness 
to  lymphatism  and  to  post-operative  toxaemia  (delayed  chloroform  poisoning, 
or  acidosis). 

As  regards  old  age,  two  points  have  to  be  carefully  weighed.  A  person 
advanced  in  years  must  have  considerable  stamina  to  attain  his  age,  and  so  is 
usually  a  good  subject.  Indeed,  age — and  this  is  the  second  and  more  important 
point — must  be  reckoned  less  by  years  than  by  the  healthiness  of  the  tissues, 
especially  of  the  lungs  and  blood-vessels. 

To  return  to  the  question  of  children,  it  is  beyond  the  scope  of  our  present 
purpose  to  discuss  whether  lymphatism — status  lymphaticus — exists  as  a 
pathological  entity  ;  it  is  proposed  to  discuss  the  symptoms  and  pathological 
conditions  grouped  under  these  headings,  and  to  indicate  their  bearing  upon 
the  question  of  the  safety  or  danger  of  anaesthesia. 

Status  lymphaticus — Lymphatism. — This  condition  is  commonly  overlooked 
in  life,  but  of  late  years  post-mortem  examinations  have  shown  certain  lesions, 
not  only  in  infants  and  children,  but  in  older  persons.  The  lymphatic  follicles 
and  glands  throughout  the  body  are  enlarged,  the  heart  is  commonly  small,  and 
the  aorta  is  sometimes  markedly  diminished  in  size.  The  chronic  enlargement 
of  the  tonsils  and  the  presence  of  post-nasal  adenoid  growths  produce  imperfect 
pulmonary  ventilation,  so  that  the  child  suffers  from  lack  of  complete  aeration 
of  its  blood  and  tissues.  There  is  frequently  a  persistent  thymus,  but  it  is  very 
doubtful  whether  this,  save  in  most  exceptional  cases,  can  produce  mechanical 
interference  with  breathing.  Its  presence  may  be  seen  sometimes  as  a  shadow 
in  a  skiagram,  although  the  absence  of  the  shadow  does  not  disprove  its  presence. 
Some  enlargement  of  the  thyroid  gland  is  present  in  about  50  per  cent  of  the 
cases  examined.  It  is  believed  by  some  authorities  that  the  condition  is 
associated  with  a  toxaemia,  due  to  internal  secretion  of  the  ductless  glands, 
which  renders  the  heart  peculiarly  liable  to  failure.  The  fat  of  the  body  is 
increased,  the  skin  is  said  to  be  harsh  and  liable  to  pigmentation,  and  the  mental 
outlook  is  perverse  ;  thus,  although  the  child  is  often  mentally  bright,  he  is 
irritable,   easily   annoyed,    and   incapable   of   much   self-control   or    prolonged 


30  INDEX    OF    PROGNOSIS 

exertion  ;  hebetude  and  introspection  focus  his  mental  attitude.  Clinically, 
the  dominating  symptom  is  the  appalling  liability  to  sudden  death  from  heart- 
failure  without  adequate  cause.  The  prick  of  a  hypodermic  needle,  the  entry 
into  a  bath,  sudden  cold,  may  claim  him  as  a  victim.  Into  this  group  come 
infantilism,  cretinism,  and  cognate  conditions. 

There  seems  little  doubt  that  although  the  incidence  of  deaths  associated 
with  this  condition  is  small  when  compared  with  the  incidence  from  other  states, 
yet  given  a  pronounced  case  of  lymphatism,  the  danger  incidence  is  great,  the 
catastrophe  ensuing  upon  mental  shock,  fear,  pain,  or  overdosage.  The  chief 
danger  appears  to  arise  in  the  large  number  of  cases  which  show  no  marked 
symptoms  in  life  ;  nor  can  one  say  definitely  that  every  case  of  a  child  with 
enlarged  hypertrophied  tonsils  and  glands  may  not  belong  to  the  type,  even 
though  his  symptoms  are  ill-defined.  That  thousands  of  such  children  pass 
through  the  ordeal  of  anaesthesia  without  scathe  goes  without  saying,  while  we 
know  that  the  use  of  a  local  analgesic  (tropacocaine)  in  a  safe  dose  has  been 
associated  with  the  death  of  a  lymphatic  patient.  It  must  be  borne  in  mind 
that  one  type  of  lymphatic  patient  is  marked  by  respiratory  danger,  the  other 
by  circulatory  catastrophe.  The  '  sudden  death  '  of  the  German  writers  is 
designated  white  death,  while  the  less  sudden  fatality  of  primary  respiratory 
origin  is  known  as  blue  death. 

It  is  probable  that  in  estimating  the  share  of  danger  from  the  anaesthetic,  we 
have  to  consider  not  only  whether  one  or  another  drug  is  more  dangerous,  but 
whether,  owing  to  the  dyscrasia,  all  drugs  are  dangerous  unless  we  are  keenly 
alive  to  the  fact  that  such  delicate  persons  cannot  withstand  the  same  doses  and 
concentrations  of  anaesthetics  as  are  well  within  the  zone  of  safety  for  the  ordinary 
individual.  It  is  less  that  the  anesthetic  is  dangerous,  than  that  it  is  the  way  the 
anaesthetic  is  presented  to  the  lymphatic  patient  which  courts  disaster.  Although 
chloroform  is  associated  with  a  majority  of  these  deaths,  it  is  not  proved  that  it 
is,  indeed,  the  most  perilous.  It  must  be  remembered  that  chloroform  is  the 
anaesthetic  of  choice  and  the  one  most  usually  employed  for  young  persons  and 
for  operations  upon  the  upper  respiratory  tract,  and  that  it  is  such  persons  who 
suffer  from  lymphatism  and  usually  require  this  type  of  operation.  It  is, 
however,  probable  that  chloroform  is  dangerous  in  status  lymphaticus  owing  to 
the  fall  of  blood-pressure  it  entails,  since  it  is  this  decline  in  blood-pressure 
which  is  peculiarly  prone  to  cause  death  in  such  cases.  When  an  inexperienced 
anaesthetist  is  administering  the  anaesthetic,  ether  or  an  ether  mixture  is  safer, 
and  offers  the  best  chance  of  success,  but  it  should  be  given  after  a  hypodermic 
injection  of  atropine.  Death  associated  with  lymphatism  has  occurred  during 
the  use  of  most  of  the  general  anaesthetics,  and  even  when  local  analgesia  has 
been  adopted. 

Acidosis — Post-operative  Toxcemia — Delayed  Chloroform  Poisoning. — Deaths 
following  what  appeared  a  normal  anaesthesia,  obtained  by  chloroform,  by  ether, 
by  ethyl  chloride,  or  by  a  mixture  of  these,  have  been  imputed  to  the  prolonged 
efiect  of  the  anaesthetic  upon  the  glandular  structure  of  the  liver  and  the  kidneys, 
as  well  as  upon  the  muscular  structure  of  the  heart.  The  onset  of  events  is 
marked  by  uncontrollable  vomiting  between  the  twelfth  and  forty-second  hours 
after  the  inhalation  ;  the  vomit  is  foul  and  watery,  greenish  in  colour  at  first, 
but  brown  later.  There  is  marked  restlessness  or  delirium,  with  intervals  in 
which  the  patient  is  apathetic,  and  this  apathy  may  end  in  fatal  coma.  The 
urine  is  scanty,  and  commonly  contains  albumin  and  diacetic  or  /3-oxybutyric 
acid.  The  breath  has  the  apple-hke  smell  of  acetone.  The  patients  are  usually 
young,  commonly  poorly-nourished  infants  or  children  ;  neither  the  gravity 
of  the  operation  nor  the  duration  of  the  anaesthesia  appears  to  count. 


ANESTHETICS  31 


In  a  large  number  of  patients  whose  urine  was  examined  before  the  anaesthesia 
and  subsequently  to  the  operation,  diacetic  acid  was  found  to  be  present  before 
operation,  and  few  of  these  developed  severe  symptoms.  Indeed,  it  has  been 
demonstrated  that  mere  change  of  dietary,  restriction  (starvation)  or  improved 
feeding,  is  associated  with  diacetonuria.  The  pathology  of  the  condition  is 
certainly  obscure,  and  not  a  few  instances  of  septic  changes  in  the  organs  have 
been  advanced  as  cases  of  '  delayed  chloroform  poisoning.'  Opie,  indeed,  has 
produced  fatty  changes  similar  to  what  is  described  as  '  delayed  chloroform 
poisoning,'  by  means  of  bacteria  {B.  coli  and  Streptococcus  pyogenes).  On  the  other 
hand,  Leonard  Guthrie  and  others  have  certainly  demonstrated  that  the  lesions — 
destruction  of  the  glycogenic  function  of  the  liver,  degeneration  of  the  paren- 
chymatous tissues  of  many  organs,  and  marked  fatty  degeneration  in  the  organs 
of  the  alimentary  tract — occur  without  the  incidence  of  sepsis,  syphilis,  or  other 
distinctive  disease.  Association  with  cyclic  vomiting  has  been  suggested,  but 
although  probable,  it  cannot  be  considered  proved.  Most  authorities  agree  that 
the  perversion  of  the  hepatic  function  leads  to  failure  of  metabolism  of  carbo- 
hydrate foods,  consequent  upon  which  is  destruction  of  glycogen  and  some 
damage  to  the  tissues,  with  liberation  of  fatty  acids.  The  condition  is, 
however,  uncommon,  and  even  those  who  have  had  wide  hospital  experience 
have  seen  few  cases,  unless  we  group  all  patients  who  incur  prolonged  post- 
operation  vomiting  as  suffering  from  this  appalling  perversion  of  metaboUsm. 
That  the  anaesthetic  is  but  one  factor  in  producing  this  toxaemia  is  obvious, 
but  that  it  may  act  in  this  way  is  equally  certain.  Experiments  on  animals 
have  demonstrated  that  repeated  inhalation  of  anaesthetics,  and  excessive 
strength  of  vapours,  as  well  as  accumulation  of  the  anaesthetic  in  the  tissues, 
produce  destructive  tissue  effects  quite  similar  to  those  described  above.  The 
association  of  this  toxaemia  with  diabetes  and  glycosuria  is  more  than  probable. 

Prognosis  is  difficult,  since  we  cannot  be  sure  if  children  with  normal  urine  may 
not  develop  acidosis  subsequently  ;  but  when  they  are  weakly,  have  suffered 
from  cyclic  vomiting,  are  febrile,  and  presumably  suffer  from  sepsis,  it  is  certainly 
grave  unless  the  anaesthetic  can  be  postponed  for  a  few  days  and  the  carbo- 
hydrate deficiency  counteracted  by  rectal  injections  of  dextrose  or  glucose.  Such 
rectal  feeding  (glucose  §j  in  saline  gvj),  given  every  three  or  four  hours,  is 
excellent  both  before  the  anaesthesia  and  as  soon  as  the  vomiting  appears.  It 
has  been  suggested  that  the  intravenous  infusion  of  saline  containing  6  per 
cent  of  dextrose  offers  even  a  better  means  of  supplying  the  requirements  of 
the  organism.  Whether  the  commonly  adopted  method  of  introducing  large 
quantities  of  alkalies  is  of  much  value  is  open  to  question  ;  it  does  no  harm, 
but  at  best  it  is  only  treating  a  symptom,  and  not  removing  the  cause  of  the 
pathological  perversion  of  metabolism.  As  has  been  stated  above,  diacetic  acid 
is  too  commonly  present  in  the  urine  of  all  patients  for  its  discovery  before 
operation  to  veto  the  employment  of  an  anaesthetic,  although  it  would  indicate 
the  selection  of  ether,  if  that  agent  is  otherwise  appropriate,  and  enforce  the 
necessity  for  careful  limitation  of  the  quantity  of  the  anaesthetic  given. 

Beesly  has  pointed  out  that  acetonuria  is  virtually  always  present  in  the  cases 
which  are  septic,  but  that  chloroform  increases  the  danger  of  fatality.  In  19 
appendix  abscess  cases  when  chloroform  was  given,  14  died  ;  in  24  when  ether 
was  administered,  2  died.  It  must  be  borne  in  mind  that  acidosis  is  the  result 
of  many  conditions,  and  so  these  have  to  be  differentiated.  Thus,  it  may  be 
{a)  symptomatic  ;  {b)  due  to  the  use  of  various  drugs  ;  (c)  associated  with 
diabetes  ;  {d)  associated  with  cyclic  vomiting  ;  (e)  associated  with  inhalation 
of  chloroform,  and  to  a  less  degree  with  that  of  other  anaesthetics,  e.g.,  anaesthol 
(Torek)  ;    (/)  associated,  as  it  commonly  is,  with  infancy. 


32  INDEX    OF    PROGNOSIS 

Anezmia,  whether  it  be  accepted  as  merely  symptomatic  of  physical  depressioa 
or  not,  is  a  very  important  factor  in  estimating  the  dangers  of  general  anaesthetics. 
It  is  stated  that  when  the  haemoglobin  falls  below  50  per  cent  of  its  normal, 
chloroform,  and  even  ether,  become  dangerous  ;  Mickulicz  accepts  30  per  cent 
below  normal  as  dangerous.  Yet  the  danger  of  operating  when  the  haemoglobin 
content  is  unduly  low  does  not  impress  those  who  see  such  perils  lurking  in 
haemolysis  produced  by  anaesthetics — for  haemolysis  certainly  occurs  as  a  result 
of  trauma  per  se.  It  is  probable  that  Snow's  dictum  is  correct,  and  that  when 
a  patient  is  judged  to  be  fit  to  undergo  an  operation,  he  is  also  fit  to  be  subjected 
to  anaesthesia.  The  main  points  which  need  attention  are — the  limitation  of  the 
amount  of  the  anaesthetic  which  is  given,  and  the  careful  selection  of  the  method. 
Haemolysis  is  less,  of  course,  when  analgesia  is  employed  ;  and  if  the  condition 
of  the  poorly-nourished  nervous  system  is  deemed  to  be  satisfactory,  the  spinal 
method  or  local  analgesia  should  replace  inhalation.  There  is,  however,  a  risk 
in  these  cases,  too  often  ignored,  of  the  supervention  of  psychic  shock  and 
consequent  circulatory  catastrophe. 

The  danger  of  chronic,  as  opposed  to  acute,  anaemia  is  greater  ;  especially  is 
this  so  if  the  blood  drain  in  the  latter  case  is  due  to  repeated  and  severe  haemor- 
rhages, such  as  occur  in  metrorrhagia.  In  the  first  case,  behind  the  condition 
is  some  serious  dyscrasia,  probably  a  perversion  of  the  blood  itself ;  in  the  latter, 
it  is  a  mere  temporary  numerical  loss  of  erythrocytes.  When  the  surgical 
aspect  of  the  case  permits  of  delay,  pre-operation  treatment  is  advisable,  and 
especially  is  this  the  case  with  young  persons.  An  infusion  method  offers  us 
the  obvious  advantage  in  these  cases  of  combining  anaesthesia  with  a  supply 
of  a  physiological  fluid  which  is  competent  to  counteract  the  deleterious 
depletion  of  the  circulating  fluid. 

Exophthalmic  Goitre-^Th-e.  incidence  of  danger  in  these  cases  is  so  great,  that 
many  continental  authorities  who  enjoy  an  experience  of  somewhat  crude 
methods  of  anaesthetizing,  discountenance  the  use  of  general  anaesthesia,  substi- 
tuting a  local  analgesia.  But  the  danger  is  not  obviated  by  this  procedure,  since 
the  psychic  shock  is  not  removed,  and  it  is  this  condition  which  makes  for  a  fatal 
result.  Unless  the  elaborate  method  of  Crile,  '  stealing  the  thyroid,'  is  adopted, 
and  local  analgesia  is  combined  with  the  employment  of  both  hypnotics  (scopola- 
mine, morphine,  and  atropine)  and  the  oxygen-nitrous  oxide  mixture,  we  have 
to  decide  whether  chloroform  or  ether  should  be  employed.  Crile's  method, 
unless  carried  out  in  its  entirety  and  to  the  last  detail,  is  not  satisfactory  ;  and 
in  this  country  it  is  difficult  to  isolate  a  patient  from  her  friends,  to  maintain 
the  mystery  as  to  the  date  of  operation,  and  ultimately  to  perform  it  without 
a  formal  consent.  A  fatal  result,  which  is  always  possible,  would  give  rise  to 
grave  questions  of  responsibility  which  needs  must  be  carefully  faced  beforehand. 

The  choice  of  the  anaesthetic  resolves  itself  into  that  of  the  method.  Un- 
doubtedly a  preliminary  drowsing  with  suitable  hypnotics  is  advisable,  whether 
local  or  general  methods  are  pursued.  Local  systems  are  admitted  to  fail  when 
the  thyroid  is  being  dislocated,  and  this  increases  the  danger.  Chloroform  with 
oxygen  is  only  safe  when  a  dosimetric  method  is  employed,  as  a  serious  fall  of 
blood-pressure  spells  disaster.  Ether,  even  if  guarded  by  atropine  and  given  by 
an  open  method,  often  causes  dyspnoea  in  goitre  cases,  owing  to  the  large  excess 
of  bronchial  secretion  it  excites.  It  has  a  further  disadvantage  in  that  its 
stimulating  effect  cloaks  the  signs  of  shock,  and  often  leads  to  the  performance 
of  a  more  extensive  operation  than  the  patient  can  bear.  As  soon  as  the  ether 
effect  has  passed,  profound  collapse  sets  in,  and  death  is  Uable  to  occur.  This 
calamity  is  especially  likely  to  ensue  when  ether  has  been  given  in  unstinted 
quantity. 


ANESTHETICS 


33 


Serious  Lesions  of  the  Nervous,  Pulmonary,  Circulatory,  Renal,  or  Metabolic 
Systems. — In  estimating  the  incidence  of  fatality  among  patients  suffering  from 
the  above,  we  have  to  consider,  less  the  actual  disease,  than  the  effects  which  it 
has  brought  about  in  the  physical  well-being  of  the  patient.  If,  in  the  case  of 
disease  of  the  nervous  system,  we  recognize  that  there  is,  or  may  be,  pressure 
about  the  pons  Varolii  or  the  medullary  centres,  we  know  that  any  profound 
narcotization  of  the  respiratory  centre  will  make  for  extreme  danger.  Again,, 
when  well-marked  arteriosclerosis  exists,  there  can  be  no  doubt  of  the  danger 
of  using  a  general  ansesthetic  given  by  any  method  which  involves  rise  of  blood- 
pressure,  since  it  promotes  a  grave  risk  of  a  cerebral  haemorrhage.  Equally 
perilous  in  cases  of  advanced  pulmonary,  bronchial,  or  pleuritic  disease  would  it 
be  to  employ  an  anaesthetic  which  would  increase  respiratory  difficulty,  and  so 
throw  back  a  strain  upon  a  heart  probably  taxed  already  to  its  utmost  capacity, 
A  mere  cardiac  valvular  lesion,  when  compensation  is  complete,  or  even  renal 
disease  confined  to  one  kidney,  need  not,  with  care,  involve  the  patient  in  greatly 
enhanced  risk  under  anaesthesia. 

Septic  Conditions. — It  has  been  said  that  the  pathological  lesions  seen  after 
septic  fever  and  after  chloroform  toxaemia  are  closely  akin.  This  fact  induces 
the  anaesthetist  to  employ  ether  in  acute  septic  cases,  either  by  inhalation, 
insufflation,  intravenous  infusion,  or  colonic  absorption  methods.  Probably 
septic  states  of  the  thoracic  walls  and  contained  viscera  alone  furnish  exceptions 
to  this  contention.  However,  as  Graham  has  shown  that  phagocytosis  is  delayed 
by  ether,  even  that  anaesthetic  is  not  without  its  risk,  while  spinal  analgesia  may 
prove  dangerous  in  marked  septicaemia,  although  safe  in  localized  disease  such  as. 
acute  appendicitis.'  If  ether  is  employed,  the  injection  of  5  oz.  of  pure  olive 
oil  per  rectum,  as  soon  as  the  patient  is  carried  back  to  bed,  has  been  shown  to> 
assist  the  rapid  return  of  the  power  of  phagocytosis. 

5.  The  Nature  and  Duration  of  the  Operation  and  Intercurrent  Conditions 
associated   therewith. 

Shock — Blood-pressure — Body  Temperature.— It  is  impossible  in  this  place  to 
go  into  any  lengthy  discussion  of  surgical  shock.  From  whatever  cause  it  arises, 
we  know  that  trauma  in  certain  regions,  and  involving  certain  structures,  appears 
to  bring  about  conditions  which  are  commonly  grouped  under  the  term  '  shock,' 
often  associated  with  surgical  procedures  which  in  themselves  do  not  seem 
serious  and  do  not  involve  any  great  '  insult  to  tissue.'  Such  operations  are 
those  which  involve  the  opening  of  the  large  somatic  or  cranial  cavities — laparo- 
tomies, coeliotomies,  opening  of  the  thorax,  exploratory  operations  on  the  brain 
and  spinal  cord.  Further,  when  viscera,  and  especially  certain  serous  membranes, 
are  dragged  upon  and  dislocated,  such  shock  eventuates.  In  the  case  of  serous- 
membranes.  Professor  Yandell  Henderson  contends  that  the  loss  of  carbon 
dioxide  produces  acapnia,  a  determining  cause  of  heart  failure.  Undoubtedly 
the  opening  of  such  cavities  leads  to  changes  in  the  haemodynamics  of  the  body 
which  may  gravely  prejudice  the  carrying  on  of  the  normal  circulation.  This 
is  indicated,  for  example,  by  the  rapid  recovery  of  the  patient  when  the  abdo- 
minal walls  are  closed.  We  know  that  shock  may  be  regarded  as  loss  of  body 
heat  and  fall  of  blood-pressure,  and  hence  it  becomes  necessary  that  the  anaesthetic, 
and  method  of  using  it,  should  be  so  safeguarded  as  to  prevent  an  additional 
declension  of  either  blood-pressure  or  body  temperature.  Since  elimination 
of  the  anaesthetic,  if  from  the  lungs  and  kidneys,  predicates  abstraction  of  heat, 
it  follows  that  the  less  anaesthetic  there  is  employed  the  less  will  be  the  drain  on 
the  body  heat. 

A  fall  of  blood-pressure  is  usually  dangerous,  but  if  the  initial  blood-pressure 
is  high,  or  if  it  is  desired  to  prevent  any  engorgement  of  the  vessels,  as  in  cranial 

3 


34  INDEX     OF    PROGNOSIS 

and  spinal  surgery,  chloroform  is  adopted  to  facilitate  the  surgeon's  work  by- 
lowering  the  blood-pressure.  The  addition  of  oxygen  removes  the  danger  of  the 
lessened  activity  of  the  respiratory  centre.  Haemorrhage  antecedent  to,  or 
involved  in,  an  operation  is  best  met  by  introducing  saline  pari  passu  with  the 
anassthetic  ;  hence  we  adopt  ether  infusion,  colonic  etherization  with  tissue 
infusion,  or  some  kindred  method. 

Prolonged  operations  are  often  necessary,  and  may  prevent  the  use  of  spinal 
methods ;  and  their  dangers  as  regards  anaesthetics  are — either  excessive  faU  of 
blood-pressure  leading  to  profound  collapse,  or  undue  stimulation  followed  by 
even  greater  collapse  after  the  anaesthetic  has  ceased  to  be  used  ;  while  an  after- 
danger  exists  owing  to  the  cooling  and  shock  engendered  by  the  eUmination 
of  the  large  amount  of  the  anaesthetic  which  has  entered  and  become  segregated 
in  the  tissues.  The  first  danger  is  that  of  chloroform,  the  second  is  that  of  ether. 
The  two  conditions  being  compared,  we  find  that  the  chloroform  collapse  is  more 
rapidly  and  more  readily  surmounted  than  is  its  counterpart  due  to  ether.  In 
prolonged  anaesthesia,  such  dangers  can  be  avoided  by  careful  moderation  of 
the  dosage.  As  time  goes  on,  especially  if  traumatic  shock  and  haemorrhage 
occur,  extraordinarily  little  anaesthetic  is  needed,  and  this  minimum  should  never 
be  exceeded. 

The  '  mixed  method '  of  using  scopolamine-morphine  and  atropine  before  the 
general  anassthetic,  is  most  valuable  in  such  cases,  as  it  allows  the  anaesthetist 
not  only  to  lessen  the  dose  required  for  induction,  but  practically  to  maintain 
anaesthesia  without  inhalation.  If  this  is  overlooked,  and  the  anaesthetist 
employs  a  large  quantity  of  the  anaesthetic,  the  patient  is  subject  to  grave  risks. 
Overdosage  causes  extreme  shock  at  the  time  of  the  operation,  and  collapse  after 
its  completion. 

Severe  or  Persistent  Vomiting. — It  is  often  necessary  to  subject  a  patient  to  an 
operation  to  relieve  a  condition  which  itself  causes  or  has  caused  severe  and 
persistent  vomiting.  Further,  it  is  often  necessary  to  perform  an  operation  upon 
viscera  interference  with  which  commonly  brings  about  serious  after-sickness. 
Vomiting,  at  all  times  troublesome,  may  actually  determine  death  through 
exhaustion,  since  sleep  and  immobiUzation  are  necessary  in  order  that  traumatized 
tissues  may  heal.  Therefore,  in  selecting  the  anaesthetic  and  method,  we 
should  take  into  consideration  the  likehhood  of  after-vomiting,  and  adopt 
measures  to  minimize  the  dangers  arising  from  it.  Patients  vary  within  wide 
limit  in  their  hability  to  vomiting. 

The  types  of  vomiting  may  be  roughly  grouped  as  follows : — 

a.  Catarrhal.  This  arises  from  irritation  of  the  gastric  mucous  membrane. 
It  is  commonly  due  to  swallowing  mucus  and  saliva  saturated  with  an  inhaled 
anaesthetic.  Children,  dehcate  women,  '  bad  sailors,'  the  obese,  and  dj^speptics 
are  most  prone  to  this  trouble.  Unless  the  patient  is  unduly  feeble  the  prognosis 
is  favourable,  as  the  condition  soon  passes  off. 

b.  Head  vomiting.  This  arises  from  circulatory^  conditions,  when  not  due  to 
operative  procedure  on  the  brain,  and  can  be  obviated  by  avoidance  of  the 
lowered  head  position.  Unless  there  is  obvious  necessitj''  for  adopting  the  dorsal 
decubitus,  a  half-sitting  posture  lessens  after-sickness. 

c.  Visceral  reflex  vomiting.  Operations,  with  or  without  general  anaesthesia, 
upon  the  appendix,  the  kidneys,  or  the  uterus,  are  pecuharly  hable  to  produce 
serious  vomiting ;    especially  is  this  so  in  regard  to  the  kidneys. 

Probably  both  [h)  and  (c)  fall  into  the  category  of  toxaemia  in  many  cases 
and  are  closely  aUied  to  the  so-called  delayed  chloroform  poisoning.  As  with  all 
patients  who  are  the  subject  of  toxaemia,  the  prognosis  is  favourable  or  the 
converse  according  as  two  factors  are  recognized  and  dealt  with  :    traumatism 


ANESTHETICS  35 


by  handling  and  dragging  upon  viscera,  and  excess  in  the  quantity  of  the 
anaesthetic  given.  A  careful  study  of  the  conditions  influencing  sickness  and 
general  '  upset  '  after  anaesthetics,  made  by  the  present  writer,  brought  out 
very  clearly  the  following  fact.  Whenever  undue  venosity  of  the  blood  was 
present,  vomiting  and  severe  after-collapse  were  developed.  This  condition  may 
exist  ab  initio,  as  in  the  case  of  chronic  bronchitics,  when  bronchitis,  emphysema, 
and  a  dilated  feeble  heart  are  dominating  the  organism  ;  in  toxaemias,  such  as 
cholsemia,  uraemia,  septicaemia ;  or  it  may  arise  through  exhaustion  of  the 
central  nerve-controls  through  collapse  following  excessive  stimulation,  or 
through  the  employment  of  unnecessarily  large  quantities  of  the  anaesthetic  or 
too  concentrated  a  vapour.  The  prognosis  is  worse  in  the  case  of  ether  than 
in  that  of  chloroform,  since  very  large  quantities  of  the  former  are  given  during 
the  operation,  and  it  is  only  after  its  completion  that  the  collapse  is  observed. 

Speaking  generally,  the  prognosis  as  regards  vomiting  after  general  anaes- 
thesia is  favourable.  Avoidance  of  '  insult  to  tissue,'  maintenance  of  body 
temperature,  minimizing  the  amount  of  the  anaesthetic,  and  avoiding  the 
swallowing  of  mucus  by  giving  atropine  or  chlorbutyl  before  the  inhalation, 
with  a  correct  placing  of  the  head — lateral  posture  during  operation,  half -sitting 
posture  later — will  prevent  serious  sickness.  The  dangers  in  severe  cases  arise 
from  the  stomach  rejecting  all  nourishment,  and  from  absence  of  sleep.  Here 
rectal  or  intramuscular  injections  of  saline  and  dextrose,  and  the  use  of 
morphine  in  suitable  cases,  will  be  efficacious.  Morphine,  however,  when  given 
after  chloroform  will  sometimes  cause  sickness,  and  in  a  curious  way.  The 
patient  recovers  from  the  anaesthetic,  without  nausea  or  sickness,  and  seems 
extremely  well  for  twelve  or  twenty-four  hours,  when  severe  vomiting  comes 
on  and  is  at  times  very  troublesome. 

Vomiting  after  spinal  analgesia  is  not  infrequently  severe  and  prolonged, 
especially  if  much  encephalalgia  exists.  Although  extremely  severe  in  a  few 
cases,  the  condition  is  transitory  and  amenable  to  treatment. 

Stercoraceous  Vomiting. — A  much  more  dangerous  condition  may  arise  in  cases 
of  intestinal  obstruction.  The  contents  of  the  stomach  and  intestines  are 
regurgitated,  rather  than  vomited  by  muscular  effort,  and  usually  the  flow 
commences  as  soon  as  the  muscular  tonus  of  the  cardiac  and  pyloric  orifices 
becomes  lessened  by  the  anesthetic.  It  occurs  both  when  general  anaesthesia 
and  spinal  analgesia  are  employed.  Unless  it  is  possible  to  prevent  aspiration 
of  the  material  into  the  air-passages,  the  prognosis  is  most  unfavourable.  Even 
initial  lavage  is  not  a  complete  safeguard,  although  it  should  be  used  when 
practicable.  As  the  back  pressure  is  constant,  when  the  stomach  is  emptied 
the  intestinal  contents  stiU  flow  into  it,  so  that  the  best  method  is  to  maintain 
a  constant  irrigation  of  the  stomach,  and  have  the  shoulders  and  head  of  the 
patient  kept  high  during  the  operation.  Laryngeal  reflex  should  be  kept 
active.  In  very  serious  cases,  intubation  of  the  larynx  with  forced  respiration, 
as  obtains  in  intratracheal  insufflation,  or  the  method  of  a  preliminary  tracheo- 
tomy suggested  by  the  present  writer^,  may  be  employed. 

6.  Post-operative  Effects. — It  is  unnecessary  to  dwell  upon  the  immediate,  and 
usually  slight,  after-effects  of  anaesthesia  or  analgesia.  The  more  serious  ones, 
i.e.,  those  threatening  life,  which  occur  within  forty-eight  hours  or  so  after  the 
operation,  are  respiratory,  circulatory,  nervous,  metabolic,  and  renal.  These 
have  all  been  dealt  with  in  the  preceding  sections,  but  may  be  summarized  in 
this  place. 

In  persons  previously  affected  by  bronchitis,  inhalation  of  unwarmed  vapour 
of  ether  or  chloroform  may  determine  a  recrudescence  of  the  disease.  It  is  most 
common  with  the  former,  partly  because  the  vapour  is  more  irritating,  and  partly 


36  INDEX    OF    PROGNOSIS 

because  it  lowers  the  body  temperature  from  o"5°  to  3°  F.  during  a  prolonged 
inhalation.  Bronchitis  following  chloroform  is,  as  a  rule,  more  severe,  and 
associated  with  greater  tissue  destruction.  Prolonged  administration  of  nitrous 
oxide  and  oxygen  in  major  surgery,  unless  the  gases  are  warmed,  may  cause 
bronchial  trouble,  but  it  is  an  infrequent  complication.  It  has  been  shown  that 
when  much  bronchorrhoea  is  caused,  the  buccal,  mucous,  and  bronchial  secretions 
are  aspirated  and  enter  the  smaller  bronchi,  setting  up  irritation.  Tight  band- 
aging, by  impeding  basal  raovements,  prevents  these  fluids  being  expelled,  and 
a  pneumonic  inflammation  is  initiated,  since  pneumococci  are  usually  present  in 
the  mouth.  As  Dr.  William  Pasteur  has  shown,  many  cases  of  so-called  '  ether 
pneumonia '  are  really  instances  of  massive  pulmonary  collapse,  due  to  trauma 
affecting  the  diaphragm.  Pneumonia  of  a  septic  type  is  liable  to  follow  profound 
narcosis  when  operations  upon  the  tongue,  jaws,  or  upper  air-passages  have  been 
performed,  and  is  due  to  aspiration  of  blood,  particles  of  growth,  pus,  or  con- 
taminated saliva  and  mucus.  Such  complications  will  usually  reveal  themselves 
within  a  week  of  inhalation. 

Prophylaxis. — -Before  the  operation,  the  teeth,  mouth,  and  nasal  passages 
should  be  assiduously  cleansed,  and  unhealthy  gums  painted  with  an  iodine 
preparation.  If  the  breath  is  foul  and  the  stomach  unhealthy,  lavage  and 
careful  asepticizing  of  the  alimentary  tract  with  salol  or  other  means  may  be 
pursued.  Atropine,  given  hypodermically,  will  lessen  or  prevent  bronchorrhoea 
and  salivation.  The  anaesthetic  vapour  should  be  warmed  and  moistened,  and 
given  so  that  the  laryngeal  reflex  is  active  subsequently  to  full  anaesthesia  (third 
degree  of  narcosis)  having  been  obtained  by  the  induction.  After  the  operation, 
the  patient's  body  temperature  must  be  maintained,  and  he  must  be  protected 
from  draughts  as  he  is  conveyed  back  to  bed. 

Hydrothorax  and  oedema  affecting  the  bases  may  follow  the  exhibition  of 
ether  by  inhalation  if  the  kidneys  are  diseased  and  albuminuria  exists.  It  may 
be  associated  with  acute  oedema  of  the  tongue  and  larynx,  and  is  usually  fatal. 
If  an  undue  quantity  of  saline  is  introduced  by  the  method  of  ether  infusion, 
pulmonary  oedema  is  a  serious  danger  ;  and  hence  strict  limitation  of  the  amount 
must  be  practised,  especially  if  renal  inadequacy  exists. 

Persons  suffering  from  angioneurotic  cedema  are  in  serious  danger  lest  the 
air-passages  should  suddenly  become  involved.  I  have  met  with  one  such  case, 
and  gave  chloroform  while  tracheotomy  was  performed.  Both  local  analgesia 
and  ether  are  contra-indicated  for  these  cases. 

All  anaesthetics, when  inhaled  in  great  quantity,  especially  if  the  oxygen  content 
of  the  blood  is  not  kept  at  about  its  normal  during  the  administration,  may 
cause  tissue  cooling,  catarrh,  irritation,  and  necrobiosis  after  the  operation. 
The  law  is  certainly  true  that  the  after-effects  of  an  anaesthetic  are,  in  severity 
and  frequency,  a  function  of  the  amount  taken.  If  the  vapour  as  it  enters  is 
warmed,  some  of  its  deleterious  effects  are  removed. 

Post-operative  headache,  back-ache,  vomiting,  oculomotor  paralysis,  and 
paralysis  of  the  bladder  and  rectum,  may  follow  spinal  analgesia.  We  do  not 
know  for  certain  whether  these  arise  through  irritation  of  the  analgesic  or  through 
alteration  in  the  amount  of  the  cerebrospinal  fluid.  Their  occurrence  is  rare, 
but  at  tiraes  these  sequelas  are  alarming.  Some  surgeons  regard  them  as  evidence 
of  errors  of  technique  ;  but  even  so  it  is  not  possible  to  avoid  them  entirely,  nor 
should  we  minimize  their  gravity  when  they  arise.  The  possibility  of  acute 
mania  or  delusional  mania  consecutive  to  operations  undertaken  under  local 
analgesia  must  be  remembered  Such  cases  are  rare  and  the  ultimate  prognosis 
is  favourable,  though  the  condition  causes  great  distress  to  the  patient's  friends. 

Reference. —  ^Buxton,  "  Fscal  Vomiting  during  Anaesthesia,  a  Suggested  Method 
of  Obviating  its  Danger,"  Brit.  Med.  Jour.,  1910,  Apr.  23.  Dudley  W.  Buxton. 


ANEURYSM.     ABDOMINAL  37 

ANEURYSM,  ABDOMINAL. — It  is  needful  to  remember  that  aneurysm 
of  the  abdominal  aorta  and  its  branches  is  an  obscure  disease,  hard  to  detect 
in  early  stages  ;  so  that  when  the  physician  meets  with  a  case  in  which  there 
is  no  doubt  as  to  the  presence  of  an  abdominal  aneurysm,  the  sac  is  already 
large.  Unhappily,  the  newer  method  of  diagnosis  by  skiagraphy  does  not  give 
as  much  help  in  the  discovery  of  aneurysms  below  the  diaphragm  as  it  does  in 
those  situated  within  the  chest.  The  stealthiness  of  the  early  stages  of  the 
disease  is  prejudicial  to  the  patient's  chance  of  recovery  ;  a  sac  that  can  be  felt 
is  not  likely  to  be  '  cured.' 

General  Outlook. — I  do  not  know  of  any  proved  example  of  complete  and 
final  cure  of  an  abdominal  aneurysm  large  enough  to  be  diagnosed  as  such. 
Of  course  there  are  examples  of  what  appeared  to  be  a  pulsatile  swelling  connected 
with  the  abdominal  aorta  failing  to  kill  the  patient ;  but  these  are  usually 
cases  of  atheroma,  and  not  of  real  aneurysm.  Again,  it  is  not  an  unusual 
experience  to  encounter  healed  abdominal  aneurysms  in  the  course  of  a  post- 
mortem examination  ;  but  these  are  small,  as  a  rule,  falling  far  short  of  the  size 
which  must  be  attained  if  the  sac  is  to  be  detected  clinically.  Moreover, 
abdominal  aneurysms  are  not  seldom  multiple  ;  in  the  patient  who  dies  from 
rupture  of  one  sac,  another  may  be  found  completely  obliterated  by  lamellae 
of  clot.  True  '  cure  '  of  abdominal  aneurysm  diagnosed  during  life  is  therefore 
almost,  if  not  quite,  unknown. 

In  spite  of  this,  patients  may  live  for  a  considerable  time  after  the  onset  of 
symptoms  ;  in  one  of  Nunneley's  series,  collected  from  the  St.  George's  Hospital 
records,  the  duration  of  the  case  extended  over  nine  years ;  while  one  of  the 
Guy's  Hospital  patients,  whose  cases  were  tabulated  by  J.  H.  Bryant,  lasted 
twelve  years.  These  are,  however,  exceptions  to  the  general  rule  ;  and  the 
average  expectation  of  life  from  the  onset  of  symptoms,  judging  from  the  86 
cases  included  in  these  two  series,  is  not  more  than  fifteen  months.  The  short- 
ness of  this  period,  as  compared  with  that  of  thoracic  aneurysm,  is  no  doubt 
largely  due  to  the  greater  difficulty  of  diagnosis  ;  it  cannot  be  ascribed  to  any 
added  element  of  danger  in  the  abdominal  variety,  for  there  is  not  the  same 
risk  of  injury  to  vital  structures  that  there  is  in  aneurysm  within  the  chest. 
Aneurysm  of  the  abdominal  aorta  is  usually  limited  to  the  retroperitoneal 
tissues,  and  it  is  into  these  tissues,  in  the  great  majority  of  instances,  that  the 
fatal  rupture  which  terminates  most  cases  occurs.  The  course  of  abdominal 
aneurysm  is  short  because  its  earlier  stages  are  not  productive  of  symptoms. 

Sudden  Death.— In  almost  two-thirds  of  Nunneley's  cases,  in  all  of  which 
the  diagnosis  was  verified  by  post-mortem  examination,  the  end  came  suddenly. 
In  nearly  all  of  these  it  was  due  to  rupture,  usually  into  the  retroperitoneal 
tissues,  rarely  into  the  peritoneal  cavity.  It  is  this  predisposition  to  rupture 
that  makes  an  abrupt  termination  rather  more  frequent  here  than  in  aneurysm  of 
the  thoracic  aorta  ;  for,  curious  as  it  may  seem  when  we  reflect  upon  the  varied 
opportunities  presented  to  the  thoracic  aneurysm  of  rupture  into  neighbouring 
hollow  viscera,  it  is  the  abdominal  aneurysm,  limited  as  it  is  by  the  parietal 
peritoneum  lying  in  front  of  it,  that  bursts  the  most  readily.  In  many  instances 
the  end  is  dramatically  sudden,  no  warning  of  its  approach  being  given  until 
the  patient  drops  dead.  In  others,  a  period  of  collapse  sets  in  abruptly,  with 
or  without  pain,  a  few  hours  before  death.  It  is  therefore  essential  to  remember 
that  when  a  patient  with  abdominal  aneurysm  faints  away,  it  is  likely  that  his 
hours  will  be  few,  particularly  if  severe  pain  accompany  the  onset  of  the  faint. 
It  is  the  more  necessary  to  bear  in  mind  this  liability  to  concealed  haemorrhage, 
because  it  is  so  rare  to  find  bleeding  from  an  abdominal  aneurysm  declaring 
itself  in  the  form  of  haematemesis,  or  melaena,  or  other  external  haemorrhage. 


38  INDEX     OF    PROGNOSIS 

Features  of  Prognostic  Significance. — Everything  that  predisposes  to  activity 
on  the  part  of  the  patient  is  prejudicial  to  recovery  or  prolongation  of  life. 
This  factor  counts  for  less,  however,  than  in  thoracic  aneurysm,  probably  because 
the  pain  of  abdominal  aneurysm  is  so  crippling  as  to  reduce  nearly  every  one 
of  its  victims  to  a  state  of  complete  invaUdism.  For  this  reason,  neither  the 
age  nor  the  occupation  of  the  patient  seems  to  have  rauch  bearing  on  his  expecta- 
tion of  life,  if  we  may  judge  from  the  records  of  cases.  Sex,  again,  is  of  little 
importance,  or  at  least  it  is  difficult  to  assess  sxiy  importance  which  may  attach 
to  it,  for  abdominal  aneurj^sm  is  a  rare  disease  in  women. 

Apart  from  such  evidences  of  rupture  as  have  already  been  mentioned,  there 
is  no  help  to  be  gained  from  the  nature  of  the  symptoms  and  physical  signs 
in  arriving  at  an  accurate  prognosis.  It  is  true  that,  in  a  very  few  cases,  surgical 
treatment  has  achieved  satisfactory  results  ;  but  the  number  of  these  is  so  small 
that  it  is  impossible  to  generalize  as  to  the  features  which  promise  success  along 
these  lines  further  than  to  say  that  extirpation  is  only  possible  when  it  is  a 
branch  of  the  aorta,  and  not  the  aorta  itself,  that  is  implicated.  Such  aneurj^sms, 
e.g.,  of  the  renal  or  hepatic  arteries,  are  diagnosed  with  the  greatest  dif&cultj^ 
and  are  oftenest  found  by  accident  or  through  exploratory  laparotomy,  so  that 
there  are  no  indications  to  enable  the  clinician  to  forecast  a  successful  result. 

Influence  of  Treatment  on  Prognosis.^ — The  question  that  we  should  hke  to 
be  able  to  answer  is  :  Does  any  more  radical  method  of  treatment  yield  better 
results  than  the  usual  plan  of  rest  in  bed,  with,  restricted  diet,  and  drugs  ? 

Proximal  ligature  of  the  abdominal  aorta  has  been  practised,  both  for  aneurysm 
of  the  aorta  and  of  its  branches,  in  each  case  with  immediately  fatal  results. 
The  hepatic  artery  has  once  been  successfully  tied  on  the  proximal  side  of  an 
aneurysmal  sac  ;  but  this  aneurysm  is  extremely  rare  and  seldom  diagnosed. 
Moreover,  in  3  other  cases,  this  operation  was  fatal.  Aneurysm  of  the  iliac 
artery  within  the  abdomen  and  pelvis  has  been  attacked  by  proximal  ligature 
in  33  instances  where  the  results  have  been  recorded  ;  recovery  ensued  in  9, 
the  operation  killing  the  remainder. 

Extirpation  is  clearly  impossible  in  nearly  every  kind  of  intra-abdominal 
aneurysm.  It  has,  however,  been  successfully  carried  out  in  the  treatment  of 
aneurysm  of  the  renal  arter^',  the  kidney  being  excised  together  with  the  sac. 

Acupuncture,  the  method  introduced  by  MacEwen,  cannot,  as  a  rule,  be 
safely  undertaken  except  after  incision  of  the  belly  wall.  It  is  true  that  in 
MacEwen's  case  this  precaution  was  not  taken,  and  the  result  was  nevertheless 
satisfactory,  the  patient  being  ahve  and  at  work  tvvo  and  a  half  years  later  ; 
in  other  cases,  however,  death  has  followed  immediately  after  needhng. 

Introduction  of  wire  into  the  sac,  Moore's  method,  has  been  practised  10 
times  for  abdominal  aneurj'sm,  death  following  more  or  less  immediatelj'  in 
all  but  2  instances.  Corriadi's  modification  consists  in  the  passage  of  a  galvanic 
current  through  the  wire  introduced  into  the  sac.  This  procedure  has  been 
put  to  the  test  in  13  instances  of  abdominal  aneurysm.  The  best  result  was  in 
one  of  Finney's  cases,  the  patient  dying,  three  and  a  half  years  after  operation, 
from  rupture  of  the  sac.  In  one  other  case  the  patient  did  well,  djdng  eight 
months  later  of  dysenter3\  The  fate  of  a  third  patient  is  unknown,  but  cure 
was  improbable.     In  the  other  cases,  death  followed  within  a  few  days. 

It  appears,  therefore,  that  all  surgical  methods  hitherto  devised  introduce  an 
unjustifiable  risk  without  offering  any  certain  advantages  to  counterbalance 
it.  One  or  two  other  plans  of  a  somewhat  less  dangerous  nature  have  to  be 
considered. 

Prolonged  proximal  compression  through  the  abdominal  wall,  the  method 
introduced  by  Murray,  of  Newcastle,  and  successfully  applied  by  him  to  one 


ANEURYSM,     INTRATHORACIC  39 

patient  who  was  alive  six  years  later,  has  its  limitations,  and  also  involves 
certain  risks.  In  the  first  place,  there  are  but  few  cases  of  abdominal  aneurysm 
in  which  the  aorta  can  be  compressed  on  the  proximal  side  of  the  sac,  which 
generally  lies  too  near  to  the  costal  border  to  leave  room  for  compression.  In 
the  second  place,  the  pressure  which  is  necessary,  if  it  is  to  be  effective,  is  such 
that  it  introduces  a  risk  of  injury  to  the  bowel  and  other  abdominal  viscera, 
and  fatal  results  have  already  been  produced  in  this  way.  A  preliminary 
laparotomy  might  remove  this  risk,  but  it  introduces  fresh  disadvantages,  so 
that  this  method  cannot  be  said  to  promise  better  results  for  most  patients 
with  abdominal  aneurysm. 

Gelatin  injection  :  there  is,  lastly,  this  method  of  Lancereaux.  Though  good 
results  have  followed  in  a  few  instances,  no  improvement  has  been  recorded 
in  the  majority  of  published  cases.  There  is  some  risk  of  tetanus  following  the 
injection,  though  this  has  been  circumvented  by  more  careful  sterilization  of  the 
gelatin.  It  is  to  be  feared  that  this  method  does  not  improve  the  patient's 
prospect  of  cure. 

It  seems,  therefore,  that  we  must  be  content,  for  the  present  at  any  rate, 
with  the  ordinary  medical  treatment,  along  the  lines  introduced  by  TufneU — 
absolute  rest,  reduction  of  diet  and  particularly  of  fluids,  and  administration 
of  potassium  iodide  in  full  doses.  This  does  not  promise  any  great  likelihood 
of  cure,  but  it  is  at  least  free  from  risk  ;  and  since  the  patient  is  already  invalided 
by  pain,  it  does  not  impose  any  great  restriction  upon  the  activities  which  he 
would  otherwise  be  free  to  pursue.  Carey  F.  Coombs. 

ANEURYSM,  INTRATHORACIC. — Aneurysm,  and  fusiform,  diffuse  dilata- 
tion of  the  aorta,  must  be  considered  apart,  since  the  factors  influencing  prognosis 
are  totally  different  in  the  two  affections.  This  article,  therefore,  is  devoted  to 
a  summary  of  the  prognostic  factors  of  sacculated  aneurysm  within  the  thorax. 

The  outlook  in  a  patient  afflicted  with  this  disease  depends  on  the  balancing 
of  two  factors  :  the  rate  of  growth  of  the  aneurj^sm,  and  the  rate  of  coagulation 
within  the  sac.  Increase  in  the  size  of  any  aneury^sm  threatens  to  end  the 
patient's  life  by  haemorrhage  ;  to  this,  in  the  case  of  aneurysm  within  the  chest, 
are  added  the  various  disabilities  and  dangers  involved  in  pressure  on  vital  or 
sensitive  organs  and  tissues. 

General  Outlook. — Does  complete  recovery  ever  occur?  In  quite  a  number 
of  autopsies,  '  healed  '  aneurysms  of  the  thoracic  aorta  and  its  branches  have 
been  found,  but  these  were  not  detected  during  Ufe.  A  few  cases  have  been 
recorded  in  which  an  aneurysm,  unmistakably  present  and  even  projecting 
through  the  thoracic  wall,  has  become  sohd  and  remained  so  for  periods  of 
over  ten  years.  The  longest  duration  of  which  I  can  find  any  record  was  in  a 
case  quoted  by  Osier,  in  which  the  patient  lived  over  twenty  years  after  the 
condition  was  first  diagnosed.  So  favourable  a  result  as  this  is,  however,  highly 
improbable,  even  in  these  days  of  early  diagnosis  by  radiography. 

As  to  the  average  duration  of  life  from  the  onset  of  symptoms,  de  Havilland 
Hall's  recently  published  figures  are  of  value,  since  they  relate  to  patients 
whose  position  in  life  enabled  them  to  take  all  possible  precautions.  In  27 
cases  carefully  followed  up,  the  average  duration  of  hfe  amounted  to  about 
three  years.  It  is  more  than  probable  that  this  period,  brief  as  it  is,  is  too  long, 
if  patients  be  included  who  are  obliged  to  work. 

In  estim.ating  the  expectation  of  life  that  can  be  held  out  to  any  given  patient, 
therefore,  it  is  fair  to  take  this  as  a  basis  :  that  though  he  may  live  for  ten  or 
fifteen  years  from  the  moment  of  discovery,  it  is  not  hkely  that  he  will  last  for 
more  than  three  years. 


40  INDEX     OF    PROGNOSIS 

Sudden  Death. — ^Thoracic  aneurysm  is  one  of  the  notorious  causes  of  sudden 
death.  To  the  dangers  never  absent  from  a  heart  whose  coronary  arteries 
are  diseased — as  they  are  in  a  majority  of  cases  of  aneurysm, — are  added  those 
of  rupture,  with  rapidly  fatal  haemorrhage  ;  and,  in  a  few  instances,  those  of 
aortic  insufficiency. 

In  de  Havilland  Hall's  experience  in  private  practice,  about  one-third  of  his 
patients   died  suddenly. 

This  sudden  termination  may  be  due  to  cardiac  failure  or  to  rupture.  The 
omens  pointing  to  the  former  possibility  are  not  different  from  those  of  chronic 
cardiac  disease  generally  ;  paroxysmal  cardiac  pain,  dyspnoea  on  exertion, 
the  alternating  pulse,  and  physical  signs  of  aortic  regurgitation,  all  enhance  the 
risk  of  an  abrupt  failure  of  the  contractile  power  of  the  heart.  In  de  Havilland 
Hall's  Westminster  Hospital  statistics,  over  40  per  cent  of  the  deaths  were  due 
to  cardiac  failure.  Aneurysms  pointing  externally  rarely  burst  suddenly  ; 
indeed,  leakage  of  blood  into  the  subcutaneous  tissues  may  continue  for  quite  a 
long  while  in  such  cases  without  foreshadowing  rupture,  and  the  patient  may 
die  eventually  of  exhaustion  or  some  such  cause.  Aneurysms  of  the  intra- 
pericardial  aorta  are  particularly  liable  to  burst  into  the  pericardial  sac  ; 
this  is  immediately  fatal,  but  in  most  cases  the  diagnosis  has  not  been  made. 
Fatal  haemorrhage  occurs  more  frequently  in  patients  who  present  evidences 
of  pressure  on  the  trachea,  bronchi,  or  oesophagus,  than  in  those  who  do  not 
show  these  signs.  The  rupture  may  also  pour  its  blood  into  the  mediastinal 
tissues  ;  this  also  is  more  likely  to  happen  if  the  sac  arise  from  the  transverse 
or  descending  part  of  the  arch.  Curiously  enough,  patients  in  whom  the 
aneurysm  bursts  into  a  great  vessel — superior  vena  cava  or  pulmonary  artery 
— often  survive  the  immediate  shock  of  the  catastrophe  and  Kve  for  weeks  or 
months.  A  common  direction  of  rupture  is  into  the  left  pleural  sac  ;  this  is 
particularly  apt  to  occur  in  aneurysm  of  the  descending  aorta,  and  kills  quickly. 

Features  of  Prognostic  Significance. — The  age  of  the  patient  has  a  little  bearing 
on  the  outlook  ;  the  older  the  patient  the  better  the  prognosis.  "  Healed 
aneurysm  is  rarely  seen  in  a  man  under  forty  "  (Osier).  This  is  partly  due  to 
the  quieter  life  of  elderly  men. 

The  sex  is  of  some  importance  ;  women  carry  aneurysms  without  final  mis- 
adventure longer  than  men,  presumably  because  they  are  subjected  to  less 
physical  strain. 

The  occupation  and  social  position  of  the  patient  is  a  consideration  which 
influences  the  prognosis  along  the  same  lines  ;  the  man  who  can  take  things 
quietly,  and  rest  as  much  and  as  long  as  he  needs,  stands  a  far  better  chance 
than  the  man  who  must  work  or  starve.  Of  course,  there  are  extraordinary 
exceptions  ;  men  with  large  aneurysms  have  been  known  to  work  at  laborious 
occupations  for  years,  but  the  great  majority  are  not  so  fortunate. 

Most  thoracic  aneurysms  are  syphihtic  in  origin,  and  result  directly  from 
spirochaetal  infection  of  the  aortic  wall.  Unhappily,  it  is  not  always  possible 
to  detect  this  morbid  process  in  the  pre-aneurysmal  stage,  and  once  the 
aneurysmal  sac  has  reached  such  dimensions  that  it  produces  s3^mptoms,  the 
aortic  wall  is  injured  beyond  repair ;  yet  early  diagnosis,  such  as  is  now 
possible  by  means  of  radiography,  does  undoubtedly  improve  the  patient's 
chance.  "This  comes  about  in  two  ways  :  vigorous  mercurial  treatment,  if 
instituted  as  soon  as  the  diagnosis  is  made,  prevents  extension  of  the  aortic 
disease ;  and  the  patient  also  comes  under  restraining  influences  in  time  to 
obviate,  or  at  any  rate  to  postpone,  disaster. 

The  site  of  the  aneurysm  has  a  most  important  bearing  on  the  patient's  hope 
of  survival.     Something  has  already  been  said  about  this  in  considering  the 


ANEURYSM.     INTRATHORACIC  41 

risks  of  sudden  death.  Broadly  speaking,  it  is  the  aneurysm  that  springs 
from  the  ascending  extrapericardial  portion  of  the  aorta  that  lasts  longest ;  its 
tendency  is  to  extend  to  the  right  into  the  lung,  or  forward  by  erosion  of  the 
chest  wall,  and  in  spreading  in  either  of  these  directions  it  encounters  structures 
of  relatively  little  importance  :  the  pain  that  is  caused  by  injury  of  intercostal 
nerves  wears  the  patient's  strength  down  ;  but  when  the  aneurysm  bulges  forward 
as  a  definite  tumour  consisting  mainly  of  solidly  packed  clot,  it  is  astonishing 
how  long  life  may  last.  Even  when  the  swelling  has  attained  a  very  large  size, 
the  patient  may  carry  it  for  months,  or  even  years.  The  writer  recollects  one 
such  case,  in  which  the  aneurysmal  sac  presented  over  the  greater  part  of  the 
right  front,  below  the  right  costal  border,  and  also  below  the  inferior  angle 
of  the  right  scapula  ;  and  yet  the  patient  survived  in  hospital  for  several 
months,  and  died  eventually  of  exhaustion,  though  the  sac  had  leaked 
through  the  front  of  the  chest  wall  for  weeks.  One  of  the  worst  things 
that  can  happen  to  an  aneurysm  arising  from  this  part  of  the  arch  is  rupture 
into  the  superior  vena  cava  ;  this  often  leads  to  death  in  a  few  days,  though, 
in  one  case  seen  by  the  writer,  the  patient  survived  for  several  months  after 
the  rupture  occurred.  Rupture  into  the  pulmonary  artery  is  less  immediately 
fatal,  especially  when  the  communication  is  established  gradually,  as  it  is  in 
some  cases. 

The  most  quickly  fatal  form  of  aortic  aneurysm  is  that  which  arises  from 
the  intraperitoneal  portion  ;  this  type  shares  with  coronary  aneurysm  a  peculiar 
predilection  for  rupture  into  the  pericardial  sac,  a  calamity  which  is  fatal  at 
once,  or  in  a  very  short  time.  Possibly  earlier  diagnosis  might  help  to  avert 
this  ;  but  even  with  the  x  rays  it  is  not  easy  to  be  sure  of  the  presence  of  this 
type  of  aneurysm,  and  while  it  is  still  comparatively  small,  the  fatal  rupture  is 
apt  to  occur. 

Aneurysms  springing  from  the  transverse  aorta  are  especially  dangerous  on 
account  of  their  proximity  to  vital  organs,  and  to  hollow  viscera  into  which 
rupture  may  occur.  Approximately  one-third  burst,  especially  into  the  trachea, 
left  bronchus,  or  oesophagus,  or  into  the  left  pleural  sac.  The  danger  of  rupture 
may  be  apprehended,  therefore,  when  the  physical  signs  point  to  the  existence 
of  pressure  in  these  directions  ;  and  particularly  if  the  sac  appears  to  be  dribbling 
into  one  or  other  of  the  hollow  tubes.  Apart  from  the  danger  of  rupture, 
there  is  that  of  interference  with  important  functions  ;  asphyxia  from  pressure  on 
the  trachea  may  end  the  patient's  life ;  the  oesophagus  may  be  compressed  and 
swallowing  hindered  ;  or — more  probable  still — pressure  on  the  left  bronchus 
may  lead  to  retention  of  secretions,  with  bronchopneumonia  or  some  other 
form  of  pulmonary  infection.  Any  evidence  pointing  to  such  occurrences  is 
of  the  gravest  import,  for  pulmonary  infections  of  this  type  do  not  take  long 
to  kill. 

Aneurysms  of  the  descending  portion  of  the  arch  and  of  the  descending  intra- 
thoracic aorta  are  very  apt  to  rupture,  especially  into  the  left  pleural  cavity  ; 
in  Dr.  Oswald  Browne's  statistics,  collected  from  St.  Bartholomew's  Hospital, 
this  was  the  end  of  more  than  one-third  of  the  cases  of  descending  thoracic 
aneurysm.  Next  after  this  comes  rupture  into  the  oesophagus  or  left  bronchus. 
The  sac  that  bursts  in  these  directions  is  often  quite  small ;  the  writer  recollects 
making  an  autopsy  in  a  case  of  fatal  haemorrhage  into  the  oesophagus  from  an 
aneurysm  no  larger  than  a  walnut.  When  the  difficulties  of  diagnosis,  and 
therefore  the  improbability  of  early  treatment,  are  taken  into  account,  it  is 
easy  to  see  why  the  prognosis  is  so  gloomy  in  cases  of  descending  thoracic 
aneurysm. 

Dissecting  thoracic  aneurysm,  curiously  enough,  often  spares  its  victim  for 


42  INDEX    OF    PROGNOSIS 

years  after  the  etiological  rupture  has  taken  place.  A  case  of  survival  for 
thirty  years  is  on  record,  and  there  are  others  nearly  as  long. 

Aneurysms  arising  from  the  great  vessels,  in  the  intrathoracic  portion  of  their 
course,  have  yet  to  be  considered.  It  might  appear  that  the  prognosis  would 
be  more  favourable  in  such  cases,  since  they  seem  to  offer  a  possibility  of  surgical 
attack.  As  a  matter  of  experience,  however,  the  outlook  is  no  better  than  in 
the  case  of  aortic  aneurysm.  The  sac  so  often  arises  close  to,  if  not  actually  at, 
the  point  where  the  vessel  leaves  the  aorta,  and  the  aorta  itself  is  so  frequently 
the  seat  of  advanced  syphilitic  disease,  and  even  of  a  second  aneurysm,  that 
little  more  chance  of  successful  treatment  is  offered  than  in  the  case  of  aortic 
aneurysm. 

Lastly,  there  are  one  or  two  general  considerations. 

Multiplicity  of  Aneurysms. — The  possibihty  of  these  must  never  be  forgotten. 
Occasionally,  the  sac  which  is  obvious  may  be  undergoing  solidification,  while 
another  undetected  aneurysm,  or  a  new  pouch  of  the  primary  sac,  may  be 
spreading  in  a  different  direction.  Before  a  favourable  prognosis  can  be 
given,  therefore,  every  effort  must  be  made  to  exclude  the  presence  of  a 
second  sac. 

Situation  of  Hcsmorrhage. — Speaking  broadly,  haemorrhage  to  the  surface, 
whether  direct  or  through  a  hollow  viscus,  is  less  deadly  than  internal  bleeding  : 
it  may  stop  itself  by  the  fall  in  blood-pressure  which  it  induces ;  whereas,  in 
haemorrhage  into  a  closed  space,  there  is  not  only  loss  of  blood,  but  also  disturb- 
ance of  internal  pressure,  to  be  considered.  Rupture  into  the  pericardial  sac, 
for  example,  is  fatal,  not  because  it  deprives  the  patient  of  blood,  but  because 
it  embarrasses  the  heart. 

Evidence  of  Solidification. — The  most  favourable  omens  in  any  case  of  thoracic 
aneurysm  are  those  which  point  to  solidification  by  deposition  of  fibrin  ;  they 
are  limitation  of  pulsation,  hardening  and  shrinkage  of  the  sac,  and  increase 
in  the  density  of  the  A^-ray  shadow.  Unhappily,  it  is  not  possible  to  study  these 
processes  satisfactorily  in  many  cases  ;  only  those  which  are  pointing  through 
the  thoracic  wall  can  be  palpated  ;  but  when,  in  such  cases,  the  tumour  is 
becoming  harder  and  throbs  less,  the  outlook  is  relatively  favourable.  Even 
so,  the  possibility  of  spread  in  another  direction  must  be  kept  in  mind. 

Influence  of  Treatment  on  Prognosis. — Is  it  possible  to  say  that  the  outlook 
is  improved  by  the  adoption  of  any  particular  line  of  treatment  ?  The  results 
achieved  by  the  various  plans  of  treatment  in  use  must  be  compared  in  order 
to  answer  this  question. 

First,  there  is  what  may  be  called  the  ambulatory  plan.  The  patient  is 
restrained  from  severe  exertion,  but  he  is  allowed  to  walk  about  and  do  his 
business,  provided  it  does  not  entail  heavy  labour ;  drugs,  usually  potassium 
iodide  in  full  doses,  being  given  meanwhile.  Remarkably  good  results  are 
achieved  in  some  cases,  particularly  when  the  patient  is  a  reasonable  being, 
and  able  to  regulate  his  life  wisely  ;  but  over  against  these  successes  must  be 
set  a  large  number  of  failures,  including  a  considerable  percentage  of  sudden 
deaths  from  rupture.  It  is  impossible  to  form  a  definitely  calculated  estimate 
of  the  expectation  of  life  to  be  offered  to  the  patient  who  chooses  this  plan, 
or  is  obliged  to  be  content  with  it;  but  the  writer,  judging,  from  out- 
patient experience,  would,  on  an  average,  place  it  at  something  within 
two  years. 

Second,  the  Tufnell  plan  must  be  considered.  This  term  includes  absolute 
and  prolonged  rest,  with  restriction  of  diet,  especially  in  the  matter  of  fluids  ; 
convalescence  is  jealously  guarded,  and  there  is  no  eventual  return  to  heavy 
bodily  work.     Here  again  it  is  very  difficult  to  supply  figures,  for  a  large  number 


ANEURYSM     OF    PERIPHERAL    ARTERIES  43 

of  patients  undergo  treatment  which  is  a  compromise  between,  or  combination 
of,  this  plan  and  the  preceding  one.  De  Havilland  Hall's  figures,  relating  to 
27  cases,  show  that  the  average  expectation  of  life  in  patients  who  have  followed 
the  Tufnell  plan  for  as  long  as  they  could  endure  it,  and  have  subsequently 
ordered  their  lives  as  peaceably  as  they  might,  is  about  three  years  from  the 
onset  of  symptoms.  Remarkable  successes  are  sometimes  achieved  by  this 
plan,  provided  the  period  of  absolute  rest  be  repeated  from  time  to  time  as 
symptoms  dictate  ;  and  from  a  survey  of  the  available  facts,  the  writer  is 
inclined  to  claim  that  a  higher  percentage  of  survivals  over  five  years  is  to 
be  found  among  patients  undergoing  this  than  among  those  following  any 
other  method. 

Third,  the  gelatin  treatment,  introduced  by  Lancereaux,  was  rather  discounted 
at  first  by  the  fact  that  it  was  followed  by  tetanus  in  a  few  cases.  This,  however, 
can  be  avoided  ;  and  the  method  has  been  fairly  tried.  Kingston  Fowler's 
results,  in  12  cases  treated  along  these  lines  at  the  Middlesex  Hospital,  did  not, 
in  his  opinion,  show  any  superiority  over  those  attained  by  other  methods. 

Lastly,  surgical  methods  remain  to  be  considered.  Attempts  at  extirpation 
of  an  intrathoracic  sac  arising  from  the  aorta  have,  without  exception,  been 
immediately  fatal.  According  to  Monod  and  Vanverts,  who  examined  records 
of  77  recent  cases  of  innominate  aneurysm  treated  by  distal  ligature  of  the 
common  carotid  with  the  subclavian  or  axillary  artery,  temporary  improvement 
followed  in  57  per  cent,  immediate  death  in  14  per  cent,  and  the  remainder  were 
classed  as  failures. 

Of  late  years  American  clinicians  have  given  a  thorough  trial  to  wiring 
methods,  i.e.,  treatment  by  the  introduction  of  wire  into  the  sac  of  the  intra- 
thoracic aneurysm,  with  or  without  the  passage  of  a  galvanic  current  through 
the  wire.  Even  when  due  allowance  is  made  for  the  desperate  nature  of  the 
cases  to  which  such  a  plan  is  likely  to  be  restricted,  the  results  cannot  be 
regarded  as  encouraging.  In  Eshner's  table  of  38  cases,  death  followed  in 
exactly  half,  within  a  month  of  the  operation ;  but  i  patient  survived  for 
twelve  years.  Of  Hall's  22  cases,  i  lived  for  five  years ;  and  of  Finney's 
23  cases,  I  lived  for  three  years.  Regarded  from  the  prognostic  view,  there- 
fore, it  does  not  seem  that  longer  life  can  be  promised  to  the  patient  who 
submits  to  this  operation. 

To  sum  up,  the  truth  is  that  the  outlook  in  any  case  of  thoracic  aneurysm  is 
bad  ;  the  average  expectation  of  life  is  not  more  than  three  years,  and  even 
this  brief  period  is  not  likely  to  be  attained  if  the  sac  be  projecting  backwards 
from  the  transverse  or  descending  aorta.  Life  is  more  likely  to  be  prolonged 
if  the  patient  is  able  to  submit  himself  to  the  ordeal  of  complete  rest  with 
restriction  of  diet,  and  if  the  diagnosis  be  made  early.  Carey  F.  Coombs. 

ANEURYSM  OF  PERIPHERAL  ARTERIES.— Although  spontaneous  cure 
of  a  peripheral  aneurysm  has  been  known  to  occur,  it  must  be  very  rare.  In 
these  days  of  surgery  it  is  almost  invariably  the  practice  to  operate  instead 
of  waiting  to  see  what  nature  might  do  ;  but  in  the  pre-antiseptic  era  various 
methods  of  natural  cure,  by  extension  of  clot  from  the  sac,  '  plastic  arteritis,' 
pressure  of  the  sac  on  the  artery,  etc.,  were  described,  and  in  a  few  cases  an 
aneurysm  has  been  known  to  slough  away  en  masse. 

Further,  aneurysms  are  not  always  progressive,  but  may  last  for  years  without 
appearing  to  do  any  harm.  In  the  end,  however,  the  recorded  cases  all  required 
treatment  for  severe  symptoms.  The  writer  has  seen  a  carotid  aneurysm  in  a 
woman  who  had  had  it  for  many  years  and  suffered  little  or  no  inconvenience, 
and  was  therefore  unwilling  to  have  it   operated  on.     They  are  more  rapidly 


44 


INDEX    OF    PROGNOSIS 


progressive  in  the  young  and  vigorous  than  in  feeble  old  persons  with  a  reduced 
circulation. 

The  life  of  a  patient  wdth  an  aneurysm  is,  however,  always  in  jeopardy. 
Sooner  or  later  it  is  liable  to  rupture  into  the  subcutaneous  tissues  or  externally, 
causing  rapid  death  from  loss  of  blood,  or  such  grave  disiategration  of  the 
cellular  planes  as  may  lead  to  the  necessity  for  amputation.  Occasionally 
suppuration  may  take  place.  The  deadly  nature  of  the  disease  is  emphasized 
by  the  fact  that  even  in  the  infancy  of  the  surgical  art,  before  anaesthetics  or 
antiseptics  had  robbed  it  of  its  terrors,  when  nothing  but  the  direst  necessity 
led  the  surgeon  to  abandon  the  expectant  method  and  perform  a  major  opera- 
tion, there  were  a  number  of  well-estabhshed  methods  for  the  operative  treat- 
ment of  aneurysm.  Apparently  the  condition  used  to  be  commoner  than  it  is 
now.  We  must  allow  due  weight  to  the  experience  of  these  early  surgeons, 
that  the  poUcy  of  letting  an  aneurysm  alone  usually  led  to  disaster ;  but  the 
exact  frequency  of  such  disaster  we  have  no  figures  to  show,  nor  are  we  Ukely 
to  have  in  the  future. 

Treatment  by  Compression  has  almost  been  given  up,  except  where  operation 
is  quite  impossible.  It  is  painful  and  tedious  (the  average  time  in  26  cases 
was  nineteen  days).  It  only  cures  a  minority  of  the  cases  ;  thus  Barwell  found 
that  of  148  instances  of  popliteal  aneurysm  treated  by  compression  between 
1870  and  1880,  68  succeeded  and  80  failed.  It  may  reduce  the  prospects  of 
success  of  the  subsequent  ligature  by  dilating  up  the  collateral  circulation. 

Treatment  by  Operation. — We  are  greatly  indebted  to  the  excellent  studies 
of  the  literature  by  Monod  and  Vanwerts  for  our  knowledge  of  the  end-results 
of  the  various  methods  of  treatment  of  aneurj'sm.  They  have  done  their  best 
to  eliminate  the  usual  fallacies  of  statistics  collected  from  recorded  cases 
instead  of  consecutive  hospital  series,  but  it  is  probable  that  successes  and 
new  methods  figure  a  little  too  prominently  even  in  their  carefuUy-compiled 
tables. 

In  a  study  of  410  recorded  cases,  they  found  that  after  proximal  hgature 
about  three-quarters  were  cured,  12  per  cent  failed,  and  6-5  per  cent  suffered 
from  gangrene.  There  was  often  persistent  pain  from  adhesions  of  nerves  to 
the  sac. 

Of  cases  treated  by  extirpation,  90  per  cent  were  cured,  and  4  per  cent 
developed  gangrene. 

Of  105  cases  treated  by  Matas'  method  of  aneurysmorrhaphy,  conserving 
the  artery  if  possible,  85  were  cured  and  12  died. 

Their  results  may  be  set  out  in  tabular  form  thus  : — 


Aneurysms   or  Old  Arterial  H.ematomata. 


Method 

Cases 

Cured 

Died 

Gangrene 

Failure 

per  cent 

per  cent 

per  cent 

per  cent 

Ligature     

138 

74 

rr 

I 

6-5 

12 

Extirpation         .         .         .         - 

205 

90 

3 

4 

1-5 

Antvllus     .         -         -         -          - 

41 

80 

17 

25 

0 

Aneurysm,  oblit.* 

62 

88 

8 

7 '5 

0 

Op.  conservativ.  j 

46 

73 

20 

0 

22 

*  Slatas*  obliterative  aneurysmorrhaphy. 
t  llatas'  reconstructive  methods. 
(The  percentages  do  not  always  total  exactly  100,  because  they  are  expressed   in  round  figures,  and  soma 
ol  the  gangrenous  cases  also  died.) 


ANEURYSM     OF    PERIPHERAL    ARTERIES 


45 


The  following  tables  are  quoted  by  Tscherniachowski  from  various  sources 
to  illustrate  the  frequency  of  occurrence  of  gangrene  after  various  older  methods 
of  operation  : — 


Arm 

Leg 

Total 

Cases 

Ganfirene 

Cases 

Gangrene 

Cases 

Gangrene 

Monod     r  Ligature 
and        '.  Antyllus 
Vanwerts    t Extirpation 

10 

5 

32 

per  cent 
0 

c 

0 

68 
19 

145 

per  cent 

11-7 
5-2 

6-2 

78 

24 

177 

per  cent 

10-2 
4-1 
5 

f  Ligature 
Wolff      -^Antyllus      - 
(.Extirpation 

12 

2 

11 

16-6 
0 
0 

71 
5 

44 

19-7 

20 

18-1 

83 

7 

55 

19-3 
14-2 
14-5 

After  aneurysmorrhaphy,  gangrene  occurred  in  3-3  per  cent,  and  recurrence 
in  2-7  per  cent,  of  149  cases  extracted  from  the  literature  by  Gardner  (1910). 

We  shall  now  take  up  the  principal  arteries  in  turn. 

Popliteal  Aneurysm. — Of  20  cases  treated  by  the  older  methods  in  the  London 
Hospital,  ligature  in  Scarpa's  triangle  gave  the  best  results,  but  the  literature 
quoted  above  shows  that  extirpation  is  better  on  the  whole. 

Monod  and  Vanwerts  compare  the  older  methods  with  the  conservative 
operation  of  Matas  thus  (in  some  cases  the  result  is  not  known,  hence  the  tables 
appear  not  to  balance)  :— 


Method 

Cases 

Cures 

Deatlis 

Gangrene 

Failure 

Conservative  operation 
Non-conservative  operation  - 

38 
206 

32=88-8% 
180=87-3% 

0 

5=2-4% 

0 

14=6-8% 

4=11-1% 
6=3% 

Gangrene  has,  however,  been  known  to  follow  aneurysmorrhaphy.  It  will 
be  seen  that  the  proportion  of  cures  is  about  the  same  ;  the  ligature  and  extir- 
pation methods  run  more  risk  of  gangrene,  whereas  the  Matas  operation  is 
more  likely  to  be  followed  by  recurrence. 

Femoral  Aneurysm. — Here  again  the  cures  are  about  the  same  with  the 
older  and  the  newer  methods,  and  one  has  to  balance  risks  of  recurrence  against 
risk  of  gangrene. 

Monod  and  Vanwerts  have  obtained  the  following  statistics  from  the  litera- 
ture : — 


Method 

Cases 

Cures 

Deaths 

UanSrene 

Failure 

Conservative  operation- 
Non-conservative  operation  - 

34 
166 

31=91% 
149=90% 

2=5-8% 
11=7-2% 

0 

7=4-3% 

1=3% 
0 

The  authorities  differ  as  to  whether,  if  ligature  is  adopted,  it  is  wiser  to  tie 
the  common  femoral  or  the  external  iliac,  the  former  being  more  likely  to  cure 


46 


INDEX     OF    PROGNOSIS 


the  aneurysm,  and  the  latter  more  Ukely  to  avoid  gangrene.  No  doubt,  when 
feasible,  the  best  of  the  non-conservative  operations  would  be  the  Antyllian  or 
extirpation. 

External  Iliac  Aneurysm. — This  rare  disease  may  be  treated  by  ligature  of 
the  common  iliac  artery  by  the  intraperitoneal  route,  by  extirpation,  or  by 
aneurysmorrhaphy.  Matas  gives  the  results  as  follows,  using  only  post- 1880 
evidence,  but  the  data  are  not  very  clearly  set  forth  : — 


Method 

Cases 

Cured 

Deaths 

Gangrene 

Failure 

Ligature        .         .         .         - 

Extirpation  .         -         -         - 
Aneurysmorrhaphy 

21 

5 

7 

9 
4 

4 

10 
0 
3 

7 
1 
1 

9 
6 
1 

Of  the  7  patients  treated  by  Matas'  method,  one  became  gangrenous  and  died, 
another  relapsed  and  ruptured,  and  a  third  died  of  pulmonary  embolism.  The 
others  appear  to  have  been  cured. 

Monod  and  Vanwerts  report  9  cures  and  10  deaths  after  various  operations. 

Gluteal  Aneurysm. — There  appear  to  be  no  reliable  figures  relating  to  the 
treatment  of  this  condition  which  do  not  go  far  back  into  pre-antiseptic  times, 
and  are  therefore  valueless.  Delbet  reports  12  out  of  14  cases  cured  by  the 
operation  of  Antyllus.  Bergmann  teaches  that  cure  can  often  be  obtained 
by  the  injection  of  ferric  chloride,  and  Vanwerts  declares  that  ligature  of  the 
internal  iliac  gives  excellent  results. 

Subclavian   Aneurysm.— Monod  and  Vanwerts  report : — 


Method 

Cases 

Cured 

Failure 

Died 

Proximal  Ligature   -         -         -         - 
Extirpation       .         -         .         .         - 

63 
11 

44 

10 

9 
0 

10 

1 

For  many  years  a  curious  fatality  hung  over  the  operation  of  tying  the  first 
part  of  the  subclavian,  and  the  first  19  cases  all  died,  but  the  last  10  French 
cases  have  all  recovered  (up  to  191 1). 

Axillary  Aneurysm. — Using  once  more  the  statistics  of  Monod  and  Vanwerts  : 


Method 

Cases 

Cures 

Deaths 

Gangrene 

Failure 

■Conservative  operation  - 
Non-conservative  operation  - 

6 

63 

4=66-6% 
51=81% 

1=16% 
3=4-7% 

1=16% 
2=3% 

1=16% 
5=8% 

The  non-conservative  operations  include  ligature  of  the  subclavian,  extirpation, 
and  the  method  of  Antyllus,  whereof  extirpation,  when  possible,  is  the  best. 

Innominate  Aneurysm. — It  is  very  seldom  possible  to  apply  a  proximal 
ligature,  but  a  considerable  number  of  cases  have  been  treated  by  tying  the 
carotid  and  subclavian  arteries.  In  the  older  literature  there  was  a  heavy 
mortality  from  sepsis  and  haemorrhage,  and  out  of  120  cases  only  7  cures  resulted 
(Jacobsthal) ;  but  Vanwerts  is  able  to  quote  77  recent  operations,  whereof  14 
per  cent  died,  57  per  cent  improved,  and  19  per  cent  failed. 


ANGINA     PECTORIS 


47 


Carotid  Aneurysm. — Monod  and  Vanwerts  could  only  find  one  case  of 
aneurysmorrhaphy,  which  was  fatal.  The  results  of  the  older  methods  may 
be  set  out  thus  : — 


Method 

Cases 

Cures 

Deaths 

Failure 

Ligature  ------ 

Extirpation       -          -          -          -         - 

Incision    ------ 

Aneurysmorrhaphy  .          -          -          - 

16 

17 

3 

1 

13 

14 

2 

0 

0 

3 

1 
1 

3 
0 
0 
0 

Arteriovenous  Aneurysm. — This  is  usually  the  result  of  a  stab  or  bullet 
wound,  and,  as  Makins  has  pointed  out,  it  is  wise  to  wait  some  months  after 
the  latter  injury  before  operating.  Mere  proximal  ligature  may  reduce  it  to 
an  aneurysmal  varix,  but  will  not  be  curative  ;  the  essential  point  is  to  separate 
the  artery  and  the  vein.  Vanwerts  has  collected  15  cases  of  quadruple  ligature 
of  the  artery  and  vein  each,  above  and  below;  3  became  gangrenous,  and  9 
were  cured.  Extirpation,  practised  in  117  cases,  gave  95  per  cent  of  cures, 
and  1-7  per  cent  gangrene.     Nowadays  arteriorrhaphy  might  well  be  tried. 

Gangrene  is  of  course  more  likely  to  follow  operation  on  the  common  femoral 
or  popliteal  than  on  the  vessels  of  the  arm  or  the  superficial  iemoral. 

Aneurysmal  Varix. — In  the  great  majority  of  cases  this  does  no  harm,  and 
a  bandage  is  sufficient  treatment.  If  it  is  necessary  to  do  anything,  the  best 
results  have  followed  ligature  of  the  artery  above  and  below  ;  simple  proximal 
ligature  is  futile.     Arteriorrhaphy  would  be  worth  a  trial. 

References. — Keen's  Surgery,  1909,  vol.  v,  article  "Aneurysm";  Tscherniachowski, 
Deut.  Zeit.  f.  Chirurg.  1913,  June,  i  ;   Monod  and  Vanwerts,  Rev.  de  Chirurg.  191 1,  663. 

A.  Rendle  Short. 

ANGINA  PECTORIS.— When  we  say  of  a  patient  that  he  is  suffering  from 
angina  pectoris,  we  mean  that  he  is  troubled  by  bad  attacks  of  cardiac  pain, 
which  constitute  a  prominent  feature  of  his  case.  An  account  of  the  prog- 
nosis in  angina  becomes,  therefore,  an  account  of  the  prognostic  significance 
of  a  symptom,  and  not  a  summary  of  the  menaces  contained  in  a  definite  disease. 
Angina  pectoris  will  here  be  spoken  of  as  a  symptom  of  organic  disease  of  the 
heart  ;    imitative  attacks  will  be  alluded  to  at  the  end. 

True  angina  is  always  evidence  of  one  thing — impaired  contractility  in  the 
wall  of  the  left  ventricle.  This  is  often  (but  not  always)  associated  with  inter- 
ferences in  the  supply  of  blood  to  the  myocardium,  through  the  coronary  arteries. 
Now  inadequacy  of  contractile  power  in  the  ventricular  myocardium  is  a  serious 
matter,  and  any  lesion  that  can  produce  it  is  a  veritable  shell  in  the  engine-room . 
The  first  statement  to  be  made,  therefore,  is  that  angina  is  always  a  grave 
symptom  in  any  case  of  cardiac  disease.  Its  appearance  in  a  patient  who  has 
never  shown  any  previous  evidence  of  a  lesion  of  the  heart  must  always  call  for 
a  minute  investigation  of  the  case  from  every  point  of  view,  to  ascertain  the 
precise  nature  of  the  injury  that  is  causing  it.  On  the  other  hand,  when  a 
patient  who  is  known  to  carry  a  damaged  heart  has  his  first  paroxysm  of  angina, 
the  prognosis  is  made  graver  than  before,  simply  because  it  shows  that  the  vital 
part  of  his  heart,  the  muscle  of  his  left  ventricle,  is  becoming  unequal  to  the 
demands  which  are  made  on  it.  It  must  be  added  that  the  very  occurrence  of 
angina  introduces  into  the  case  a  risk  of  sudden  death  ;  this  point  will  be 
examined  in  detail  later.  The  average  period  elapsing  between  a  first  attack 
and  the  patient's  death  is  not  easy  to  ascertain. 


INDEX    OF     PROGNOSIS 


General  Outlook. — In  order  to  determine  the  outlook  in  any  given  case  of 
angina,  four  points  must  be  examined  :  (i)  The  nature  of  the  cardiac  lesion  ; 
(2)  The  circumstances  provoking  the  attacks  ;  (3)  The  nature  of  the  attack  itself ; 
and  (4)   The  condition  of   the  heart  after  the  attack  is  over. 

I.  The  Cardiac  Lesion. — Angina  pectoris  occurs  in  connection  with  acute  as 
well  as  with  chronic  disease  of  the  heart,  but  far  more  frequently  with  the  latter ; 
probably  because  any  acute  disease  which  injures  the  myocardium  severely  enough 
to  cause  angina  will  quickly  go  on  to  a  fatal  issue.  From  the  prognostic  point 
of  view,  a  classification  which  divides  the  myocardial  states  responsible  for  the 
occurrence  of  angina  into  those  which  are  primary  and  those  which  are  secondary, 
is  of  more  value  than  a  division  into  acute  and  chronic  lesions.  The  primary 
conditions  are  those  in  which  the  myocardium  itself  is  diseased  ;  the  chief 
examples  of  these  are  cardiosclerosis,  cardiac  syphilis,  alcoholic  degeneration  of 
the  myocardium,  and  acute  infection  of  the  myocardium  in  such  diseases  as 
rheumatism  and  typhoid  fever.  The  secondary  causes  of  angina  are  those  in 
which  the  myocardium  is  relatively  free  from  disease,  yet  unequal  to  some 
abnormal  circulatory  strain  thrown  upon  it,  the  chief  examples  of  which  are 
disease  of  the  aortic  valves  and  high  arterial  tension.  Even  this  classification 
has  only  a  limited  value,  for  the  two  classes  overlap  at  certain  important  points  : 
for  instance,  cardiac  syphilis  and  disease  of  the  aortic  valves  frequently  coincide  ; 
so  also  do  cardiosclerosis  and  high  blood-pressure.  Nevertheless,  the  classification 
is  of  some  service  in  the  present  connection  if  it  emphasizes  the  fact  that  the 
outlook  is  graver  in  those  cases  where  angina  is  directly  connected  with  disease 
of  the  myocardial  tissues  than  in  those  where  a  fairly  healthy  myocardium  is 
confronted  with  a  task  too  heavy  for  it. 

In  determining  the  nature  and  seriousness  of  the  cardiac  lesion  responsible 
for  anginal  attacks,  therefore,  it  is  necessary  to  give  an  idea  of  the  state  of  the 
myocardium,  the  arteries,  the  arterial  tension,  and  the  valves  of  the  heart.  All 
signs  pointing  to  gross  disease  of  the  myocardium  make  the  prognosis  graver  ; 
such  signs  are  feebleness  of  the  pulse  and  heart-sounds,  embryocardia  and  gallop- 
rhythm,  the  alternating  pulse,  dyspnoeic  attacks  too  readily  provoked,  oedema 
of  the  ankles.  On  the  other  hand,  if  the  impulses  be  powerful  and  thrusting,  and 
indicative  of  hypertrophy  of  the  left  ventricle,  and  signs  of  some  extraneous  cause 
such  as  aortic  incompetence  or  high  arterial  tension  be  present,  the  prognosis  is 
better,  and  particularly  where  the  extraneous  cause  is  one  that  can  be  modified 
and  reduced  by  treatment  (high  arterial  tension),  or  is,  at  least,  not  progressive 
(post-rheumatic  incompetence  of  the  aortic  valves  in  an  adult).  Of  course,  very 
high  tension  that  does  not  yield  in  the  least  to  treatment  is  a  grave  cause  of 
angina,  for  it  is  likely  to  be  progressive.  Again,  angina  as  a  symptom  of  aortic 
insufficiency  is  of  far  more  sinister  import  when  associated  with  syphilitic  disease 
of  the  aortic  valves  than  in  cases  of  post-rheumatic  valvular  disease ;  for  in  the 
former  case  there  is  sure  to  be  progressive  myocardial  disease  associated  with 
the  valvular  lesion ;  whereas,  in  the  latter  (provided  the  patient  be  over  twenty), 
the  risk  of  direct  myocardial  injury  is  remote,  and  such  myocarditis  as  may 
occur  tends  towards  recovery  and  is  not  progressive.  The  aortic  incompetence 
of  general  atheroma  hes  midway  between  the  two  ;  the  myocardium  is  directly 
attacked  through  disease  of  its  nutrient  arteries,  and  it  will  become  worse,  but 
not  rapidly  so,  as  in  the  case  of  syphihs.  Sometimes,  of  course,  the  prognostic 
import  of  the  angina  is  overshadowed  by  that  of  other  findings,  as  when  signs  of 
aortic  aneurysm  are  discoverable. 

A  general  rule  applicable  to  all  cases  of  angina,  however,  is :  the  worse  the 
myocardium,  the  worse  the  prognosis.  The  marks  of  a  bad  myocardium  are  to 
be  found  partly  in  the  patient's  own  statement,  partly  by  physical  examination, 
and  partly  by  inference. 


ANGINA     PECTORIS  49 


2.  The  Circumstances  Provoking  Anginal  Attacks. — These  circumstances  are 
of  various  kinds  ;  the  chief  are  exertion,  emotion,  meals,  and  external  cold.  In 
a  number  of  cases  no  provocation  is  discoverable,  the  attack  coming  on  while 
the  patient  is  at  rest  in  bed.  Two  obvious  generahzations  spring  into  the  mind 
at  once,  or  rather,  two  aspects  of  the  same  generahzation.  The  first  is  that  the 
more  readily  the  attacks  are  provoked,  the  worse  the  prognosis.  There  is  much 
less  menace  in  angina  which  comes  on  in  the  middle  of  a  sprint  to  the  station 
than  in  that  which  brings  to  an  abrupt  termination  an  attempt  to  walk  up  a 
barely  perceptible  incline,  even  though  the  former  be  the  severer  attack.  The 
second  is  that  if  the  provocative  cause  be  a  controllable  one,  the  outlook  is  by  so 
much  the  better.  Obviously  the  man  who  only  gets  angina  after  overloading 
the  stomach  is  in  a  better  case  than  the  one  whose  attacks  are  provoked  by  all 
sorts  of  causes,  and  by  no  apparent  cause  at  all.  In  this  sense,  it  is  better  to  have 
one  cause  for  the  attacks  than  many  ;  for  example,  the  man  who  only  gets 
attacks  when  he  stoops  to  do  his  boots  up  can  foresee  his  danger  and  circumvent 
it  by  taking  care,  while  he  who  never  kiiows  what  petty  excitement  or  effort  may 
throw  him  into  peril  cannot  be  so  precisely  forewarned,  and  thereby  forearmed. 
In  this  connection,  the  patient's  temperament  is  important ;  the  headstrong  man, 
who  will  not  be  advised,  must  expect  evil  consequences  if  he  will  ndt  curtail  his 
activities  and  hve  within  the  limitations  of  his  myocardium.  If  he  can  and  will 
avoid  such  circumstances  as  have  been  found  to  provoke  attacks,  the  prognosis 
is  better. 

3.  The  Nature  of  the  Attack  itself. — Here  it  must  be  acknowledged  that  a  priori 
reasoning  is  singularly  apt  to  mislead.  The  severe  attack  is  not  necessarily  more 
dangerous  than  the  sUght  one.  Patients  have  been  known  to  live  for  years  after 
a  tremendous  bout  of  prolonged  agony  of  mind  and  body,  while  others  sink 
rapidly  after  an  attack  which  was  so  slight  as  to  be  misinterpreted  at  the  time. 
The  one  Hne  of  inquiry  into  the  nature  of  the  attack  which  goes  to  the  root  of  the 
matter  is  that  which  seeks  to  discover  whether  or  no  there  are  evidences  of  grave 
myocardial  embarrassment  during  the  paroxysm.  Thus,  the  prognosis  is  worse 
if  the  attack  be  accompanied  by  respiratory  changes  (grouped  breathing  or 
'  cardiac  asthma  ')  ;  so,  also,  if  the  pulse  become  slow  and  there  are  evidences 
of  heart-block,  or  if  the  patient  faint  during  the  paroxysm.  Such  data  are  of 
much  more  importance  than  the  severity  and  distribution  of  the  pain.  One 
point  that  gives  some  help  is  the  effect  of  vasodilators  ;  attacks  that  are  readily 
relieved  by  the  exhibition  of  nitrites  are  less  portentous  of  evil  than  those  that 
are  refractory  to  treatment,  presumably  because  the  angiospastic  factor,  the 
one  which  is  neutralized  by  nitrites,  is  less  threatening  than  the  myocardial, 
which  is  influenced  only  indirectly  by  this  form  of  treatment. 

4.  The  State  of  the  Heart  after  the  Attack. — This  is  of  the  greatest  significance. 
Here,  again,  it  is  the  condition  of  the  myocardium  that  matters  ;  has  it  been 
definitely  and  perceptibly  worsened  by  the  attack,  or  by  the  changes  which 
provoke  it  ?  Two  or  three  examples  will  serve  to  illustrate  this  point.  A  strong 
man  of  over  seventy  had  for  some  time  been  getting  shorter  of  breath,  but  there 
had  been  no  pain  till  one  day  after  walking  up  a  very  gentle  incline ;  even  then 
it  was  not  very  severe,  and  soon  passed  off  under  treatment.  However,  the 
heart-sounds  were  feebler  after  it  than  before,  the  patient  was  bluer  and  more 
breathless,  and  the  feet  began  to  swell ;  in  a  few  days  he  died  rather  suddenly 
in  his  armchair.  In  another  case,  a  patient  with  aortic  regurgitation  of  the 
atheromatous  type,  who  had  survived  years  of  anginal  attacks,  one,  at  least, 
30  severe  and  obstinate  as  to  necessitate  the  use  of  chloroform,  died  within  a  few 
days  of  a  comparatively  slight  seizure  of  pain,  which  was  followed  by  the  develop- 
ment of  a  pericardial  rub  with  quickening  of  the  pulse.     A  third  patient,  who 

4 


50  INDEX     OF    PROGNOSIS 

had  been  troubled  with  severe  angina  for  over  a  year,  had  a  sudden  attack  in 
bed  one  day ;  on  the  following  day  his  cardiac  dullness  had  perceptibly  increased, 
and  a  pericardial  rub  was  heard  ;  a  day  later  he  died  suddenly  in  bed.  In  this 
last  case  the  right  ventricle  was  found  ruptured  at  the  autopsy.  Anything 
which  points  to  the  myocardium  having  taken  a  downward  step  during  the 
attack  points  also  to  an  active  degeneration  in  progress,  and  therefore  to  an 
early  termination.  Signs  of  pericarditis  are  particularly  ominous,  for  they  are 
manifestations  of  some  gross  change  in  the  cardiac  muscle,  such  as  infarction  or 
rupture. 

So  much,  then,  for  the  general  outlook  in  any  patient  with  anginal  attacks  ; 
it  all  turns  on  the  state  of  the  myocardium  before,  during,  and  after  the  attack, 
and  the  degree  of  overstrain  needed  to  bring  out  that  inadequacy  of  which 
angina  is  a  symptom. 

There  are,  however,  two  other  questions  which  we  must  be  ready  to  answer  : 
the  likehhood  of  sudden  death,  and  the  probability  of  recurrences  of  the  attack. 

Sudden  Death. — Patients  who  have  had  sharp  bouts  of  angina  do  not  ask  about 
the  risk  of  sudden  death  ;  they  have  tasted  its  bitterness  already,  and  know  so 
much  of  the  danger  that  they  do  not  care  to  know  more.  The  relatives,  however, 
not  seldom  want  to  know  "  whether  he  is  likely  to  go  off  in  an  attack  "  ;  and 
this  is  not  unreasonable,  for  the  patient  looks  more  than  half  dead  if  the  paroxysm 
be  at  all  severe.  Further,  writers  of  fiction  and  of  medical  text-books  have 
insisted  so  much  on  the  association  between  angina  and  sudden  death  that  the 
two  ideas  have  become  inseparably  linked  in  the  pubhc  mind.  Now,  while  it  is 
perfectly  true  that  in  a  few  dramatic  instances  the  heart  stops  during  the 
paroxysm,  it  is  equally  noteworthy  that  a  considerable  majority  of  those  who 
are  subject  to  angina  do  not  die  during  the  attack.  Having  explained  this 
to  the  friends,  it  is  advisable  to  give  a  rather  fuller  explanation  of  the  risks 
of  sudden  death  implied  in  anginal  attacks  :  that  although  the  onset  of 
cardiac  pain  must  not  be  regarded  as  necessarily  threatening  imminent  death, 
yet  the  very  occurrence  of  such  attacks  is  a  warning  that  the  muscle  of  the 
heart  is  barely  equal  to  its  work  ;  that  it  may  fail  abruptly  or  acutely  with 
or  without  forewarnings  of  pain  ;  and  that  death  is  apt  to  follow  attacks 
of  pain  after  an  interval  of  days  or  hours.  The  actual  imminence  of  sudden 
death,  in  any  given  case,  depends  entirely  on  the  conditions  found  to  underhe 
the  patient's  hability  to  angina  ;  those  points  to  which  attention  has  been 
directed  as  giving  a  key  to  the  general  prognosis  in  any  given  case  wiU  also  assist 
in  an  estimation  of  the  risk  of  sudden  death. 

Recurrence. — Another  question  that  the  patient  may  dare  to  ask  for  himself 
after  the  first  attack  bears  on  his  liabihty  to  a  return  of  the  experience.  Now 
he  may  be  quite  truly  assured  that  it  is  possible  that  he  may  never  have  it  again, 
particularly  if  that  which  provoked  the  first  attack  be  some  avoidable  circum- 
stance, such  as  going  out  insufficiently  clad  on  a  frosty  day,  over-eating,  and  the 
like.  A  surprisingly  large  number  of  persons  have  only  one  attack,  or  else  a 
few  attacks  at  long  intervals  ;  while  some  go  through  a  series,  and  come  out  into 
smooth  water  again.  Such  good  fortune  falls  especially  to  those  whose  heart 
is  in  fair  condition,  but  overtaxed  by  a  high  arterial  tension,  or  by  leaking  aortic 
valves  and  a  laborious  occupation  ;  and  only  to  such  of  these  as  are  willing  to  go 
softly.  Indeed,  it  is  here  that  the  whole  philosophy  of  angina  comes  in.  Pain 
is  a  warning,  a  protective  phenomenon,  which  says  to  its  victim,  "  Don't  do  that 
again  "  ;  if  the  anginal  patient  will  listen  to  this  advice,  he  will  escape  further 
punishment.  Where,  however,  the  heart  is  the  seat  of  syphihs,  or  the  arteries 
are  profoundly  degenerated,  the  friends  must  be  warned  of  the  likelihood  of 
recurrences,  and  of  all  that  we  have  seen  impUed  in  them.     Moreover,  it  is  well 


ANTHRAX  51 


to  bear  in  mind  the  fact  emphasized  by  Mackenzie,  that  cessation  of  pain  is  not 
always  a  good  prognostic  sign  ;  if  accompanied,  as  it  sometimes  is,  by  the  onset 
of  mitral  insufficiency,  with  anasarca  and  increasing  dyspnoea,  the  patient  may 
be  regarded  as  having  entered  on  the  last  stage  of  his  journey,  even  though  he 
may  never  again  have  any  suspicion  of  angina. 

Pseudo-angina. — A  final  word  remains  to  be  said  about  the  shadowy  group 
of  cases  designated  'pseudo-angina,'  'toxic  angina,'  and  so  on.  Climacteric 
women  are  liable  to  attacks  of  pain  which  is  more  or  less  obviously  cardiac  ;  and 
over-smoking  may  bring  on  the  same  kind  of  trouble.  Obviously,  such  attacks, 
which  do  not  depend  for  their  origin  on  organic  disease  of  the  heart,  do  not  carry 
with  them  any  menace  to  the  patient's  life  ;  moreover,  they  will  cease  to  occur 
when  the  cause  has  ceased  to  operate.  The  whole  difficulty  of  prognosticating 
truthfully  in  such  cases,  then,  lies  in  diagnosis  of  the  cause  or  causes  of  the 
attacks.  The  task  is  to  find  out  whether  or  no  we  are  dealing  with  a  sound 
myocardium  ;  if  the  physical  signs  and  other  circumstances  (the  patient's  age 
and  his  position,  consumption  of  tobacco,  nature  of  attacks,  and  so  forth)  point 
away  from  serious  disease  of  the  myocardium,  then  the  prognosis  is  good. 

Indeed,  this  is  the  whole  secret  of  successful  prognosis  in  cases  manifesting 
angina  pectoris.  It  is  a  symptom  of  myocardial  inadequacy,  and  the  prognosis 
varies  directly  with  the  state  of  the  myocardium  :  good  heart  muscle,  good 
prognosis  ;    bad  heart  muscle,  bad  prognosis.  Carey  F.  Coombs. 

ANTHRAX. — The  outlook  in  cases  of  malignant  pustule  is  much  better 
now  than  in  days  gone  by,  and  has  been  still  further  improved  by  the  introduc- 
tion of  antitoxic  sera  such  as  Sclavo's  and  Mendez's.  In  the  years  1 850-1886, 
Koch  reported  a  mortality  of  39  per  cent,  and  in  1905  Legge  estimated  the 
English  mortality  as  26-5  per  cent  (261  cases),  and  the  German  as  13  per  cent 
(446  cases).  Since  that  time  Heinemann  has  collected  statistics  which  show 
a  marked  improvement,  and  give  us  some  guide  as  to  the  relative  value  of 
different  methods  of  treatment.     He  collects  from  the  literature  : — 

268  cases  treated  by  various  ointments  and  lotions         -  9 '3  per  cent  died 

814       ,,  ,,  excision,  cautery,  caustics     -         -  7 

1073      ,,  (Buenos  Aires)  treated  by  Mendez's  serum  -  4"2  ,, 

80      ,,     treated  by  Sclavo's  serum        ....  3-7  ,, 

The  mode  of  obtaining  these  figures  probably  makes  them  too  favourable,  as 
literature  reports  are  notoriously  apt  to  publish  the  successes  and  let  the  failures 
drop  into  oblivion  ;  but  many  years  ago  Lengyel  and  Koranyi,  in  a  consecutive 
series  of  146  cases  treated  surgically,  were  able  to  report  a  death-rate  as  low 
as  9"  per  cent,  so  probably  it  is  fair  to  take  the  mortality  in  the  serum  cases  as 
5  per  cent,  and  in  those  treated  by  excision  as  8  to  10  per  cent. 

Much  depends,  of  course,  on  the  time  at  which  the  patient  is  first  treated, 
these  good  results  being  only  obtained  in  early  cases.  Death  usually  follows 
in  five  to  eight  days,  and  spontaneous  cure  is  said  to  be  quite  uncommon.  It 
would  be  difficult  to  verify  this  statement  nowadays,  because  every  case  seen 
would  be  treated. 

When  oedema  is  very  great,  the  prognosis  is  unfavourable,  and  wounds  of 
the  head  and  neck  are  more  than  twice  as  dangerous  as  those  of  the  limbs. 
When  the  temperature  is  high  and  the  patient  shows  marked  signs  of  systemic 
infection,  recovery  is  unlikely. 

Woolsorters'  disease,  that  is,  a  general  infection  either  of  the  lungs  or  intes- 
tine without  a  skin  pustule,  is  happily  rare,  but  is  extremely  fatal. 

Reference. — Heinemann,  Deut.  Zeit.  /.  Chirurg.  1912,  309.  A.  Rendle  Short. 


52 


INDEX     OF     PROGNOSIS 


ANTRAL  EMPYEMA. — [See  Nasal  Accessory  Sinusitis.) 
ANTRUM,  GROWTHS  OF.— {See  Jaws,  Tumours  of.) 

ANUS,  IMPERFORATE. — Many  years  ago,  Harrison  Cripps  made  a  study 
of  the  operation  mortality  in  this  condition  under  various  circumstances.  He 
pointed  out  that  although  the  prognosis  apart  from  operation  is,  of  course, 
hopeless,  except  in  cases  where  the  rectum  opens  into  the  vagina,  yet  occasion- 
ally the  children  may  survive  for  a  surprisingly  long  time  ;  one  infant  at 
St.  Bartholomew's  Hospital,  whose  parents  refused  operation,  was  still  alive  a 
month  later,  vomiting  faeces  three  times  a  day  ! 

Mortality  in  Ninety-eight  Cases  treated  by  Different  Operations. 


Operation 

Cases 

Deaths 

Dissection  from  the  perineum 
Puncture  from  the  perineum 
Coccyx  resected               . .              . . 
Opening  into  vagina 
Iliac  colostomy 
Lumbar  colostomy 
Miscellaneous    . . 

37 

17 

8 

14 

16 

3 

3 

14 

14 

5 

1 

11 

I 

A  study  of  37  cases  of  this  condition,  treated  at  St.  Thomas's  Hospital,  shows 
how  few  of  the  infants  grow  up  to  adult  age  in  reasonable  comfort.  An  exception 
must  be  made  in  favour  of  little  girls  with  imperforate  anus  and  recto-vaginal 
fistula.  These  survive,  and  at  some  later  period  a  plastic  operation  can  be 
performed.  It  will  be  very  dif&cult  to  get  control  without  stricturing,  however. 
The  writer  has  seen  one  such  patient  treated  with  fair  success. 

Of  the  37  cases  referred  to,  20  died  in  hospital  :  2  of  peritonitis,  5  of  shock, 
and  13  after  laparotomy  or  colostomy.  Of  the  17  who  left  hospital  alive,  10 
have  been  lost  sight  of.  Of  the  other  7,  2  died,  aged  nine  and  twelve  months 
respectively,  of  deaths  probably  unconnected  with  the  anal  condition  ;  i  died, 
aged  two  months,  of  '  wasting  '  ;  i  died,  aged  four  months,  of  intestinal  obstruc- 
tion ;  I  died,  aged  three  years,  after  operation  to  close  a  colostomy  ;  2,  aged  nine 
and  seven  years  respectively,  are  still  living,  one  quite  well,  the  other  with  a 
recto-urethral  fistula. 

Cripps  gives  case-histories  of  a  number  of  successful  recoveries. 

It  is  probably  fair  to  conclude  that  about  half  the  patients  operated  on  die 
almost  at  once,  and  that  about  half  of  the  survivors  die  in  early  infancy.  A 
quarter  of  the  total  might  survive,  as  far  as  the  anal  trouble  is  concerned,  but 
some  of  these  are  in  permanent  discomfort.  The  most  favourable  cases  are  those 
with  only  a  mere  septum  separating  the  bowel  and  the  anus,  but  it  will  be  seen 
that  one  child  Uved  to  the  age  of  three  years,  even  with  a  left  iliac  colostomy. 

References. — Cripps,  "Diseases  of  the  Rectum  and  Anus,"  3rd  ed.  ;.  St.  Thomas's 
Hosp.  Rep.,  1911,  156.  A.  Eendle  Short. 

AORTA,  DILATATION  OF. — Either  in  relation  to  thoracic  symptoms,  or  in 
the  cause  of  routine  examination,  it  is  no  uncommon  experience  to  find  evidences 
of  diffuse  dilatation  of  the  aorta.  The  introduction  of  skiagraphy  has  done 
much  to  enlighten  us  as  to  the  frequency  with  which  the  thoracic  aorta  is  dilated. 


APHASIA  53 

While  it  would  be  out  of  place  to  enter  fully  into  the  pathogenesis  of  this  condition, 
it  is  essential  to  have  some  understanding  of  the  factors  which  enter  into  its 
production.     These  are  two,  the  dynaiinc  and  the  degenerative. 

Dynamic  Origin. — The  simplest  example  of  this  kind  is  to  be  found  in  post- 
rheumatic insufficiency  of  the  aortic  valves  ;  here  there  is  little  question  of  any 
degeneration  of  the  aortic  wall ;  for  though  the  rheumatic  process  is  liable  to  injure 
this  structure,  it  seldom  does  so  to  any  intense  or  abiding  extent.  Yet  in  many 
cases  of  long-standing  aortic  regurgitation,  there  are  the  clearest  evidences  of 
a  diffuse  enlargement  of  the  arch  of  the  aorta  ;  so  much  so,  indeed,  that  many 
writers  have  recorded  such  cases  as  examples  of  '  rheumatic  aneurysms.'  The 
explanation  is  not  hard  to  find  :  each  ventricular  systole  throws  an  excess  of 
blood  into  the  aorta  and  overdistends  it.  Clearly,  there  is  no  question  of  prognosis 
here  apart  from  that  of  the  disease  itself. 

Degenerative  Origin. — This  type  of  dilatation,  on  the  other  hand,  is  perfectly 
exemplified  in  syphilis  of  the  aorta.  Here  we  have  to  deal  with  an  actual  and 
progressive  disease  of  the  aortic  wall. 

Mixed  Origin. — A  combination  of  the  two  factors  is  encountered  in  cases  of 
aortic  dilatation  combined  with  high  arterial  tension  ;  in  such  cases,  the  aorta 
stretches,  partly  because  it  is  subjected  to  an  abnormal  tension  from  within, 
partly  because  it  is — in  most  cases,  at  any  rate — the  seat  of  a  dystrophic  process. 
Even  here,  however,  the  latter  factor  is  of  minor  importance  ;  the  fact  that  the 
aorta  is  dilated,  is  of  far  less  weight  in  regard  to  prognosis  than  the  fact  that  the 
arterial  pressure  is  raised. 

It  is  clear,  from  this  brief  account  of  the  etiology  of  aortic  dilatation,  that  its 
bearing  on  the  outlook  of  any  given  case  is  that  of  its  cause,  and  it  will  be  more 
profitable  to  refer  the  reader  to  the  articles  dealing  with  cardiac  syphilis,  arterio- 
sclerosis, high  arterial  tension,  and  aortic  regurgitation,  than  to  encourage  any 
attempt  to  forecast  the  future  of  a  case  without  reference  to  the  origin  of  the 
dilatation.  Carey  F.  Coombs. 

AORTIC  DISEASE. — [See  Heart,  Valvular  Disease  of.) 

APHASIA. — The  prognosis  depends  upon  the  underlying  cause.  Most  cases 
of  aphasia  are  the  result  of  organic  lesions  of  the  cerebral  cortex.  Some  of  them 
are  due  to  embolism  from  cardiac  lesions  ;  others,  the  majority,  are  due  to  arterial 
thrombosis  ;  whereas  cerebral  haemorrhage  is  relatively  uncommon  as  a  cause. 
In  embolic  cases,  the  arterial  obstruction  usually  reaches  its  maximum  at  once, 
and  does  not  tend  to  extend.  In  thrombosis,  on  the  other  hand,  there  is  a 
tendency  for  the  lesion  to  spread  and  become  more  extensive,  corresponding  to 
the  amount  of  disease  in  the  cerebral  arteries.  Cerebral  thrombosis  occurring 
in  the  early  half  of  adult  life  is  most  likely  to  be  syphilitic  in  origin  ;  whereas,  after 
middle  life,  arteriosclerosis  may  occur,  not  only  from  syphilitic  disease,  but  also 
from  senile  arteriosclerotic  changes.  Syphilis  should  always  be  looked  for 
by  the  various  tests  at  our  command,  since  syphilitic  cases  have  a  better  prog- 
nosis, if  promptly  treated,  than  non-syphiUtic  ones.  Cerebral  abscesses  (most 
commonly  in  the  left  temporal  lobe)  and  meningitis  are  among  the  less  common 
organic  causes  of  aphasia  ;  whilst  cerebral  tumours  are  still  more  infrequent, 
producing  aphasic  symptoms  either  by  direct  infiltration  of  the  speech-centres 
or,  more  usually,  by  conipression. 

In  many  cases  of  aphasia  from  organic  disease,  there  is  a  co-existent  right-sided 
hemiplegia,  more  or  less  profound  according  to  the  situation  and  extent  of  the 
brain  lesion.  It  is  important,  however,  to  remember  that  it  is  the  cortical  part 
of  a  brain  lesion  which  is  mainly  responsible  for  the  aphasic  symptoms,  and  that 


54  INDEX     OF     PROGNOSIS 

deeper-seated  lesions  of  the  white  matter  may  produce  the  most  profound  hemi- 
plegia without  any  evidence  of  aphasia. 

In  organic  lesions  which  are  still  advancing — e.g.,  in  spreading  vascular  lesions 
of  any  sort,  in  cerebral  abscesses,  meningitis  or  tumours, — aphasia  is  not  likely  to 
improve  ;  on  the  contrary,  it  tends  to  get  worse.  But  in  cases  where  the  organic 
lesion  has  come  to  a  standstill — e.g.,  after  an  attack  of  cerebral  embolism  or 
thrombosis,  after  successful  evacuation  of  a  cerebral  abscess,  or  after  relief  of 
pressure  by  removal  of  a  cerebral  tumour  (provided  that  the  tumour  has  not 
infiltrated  the  speech-centres,  but  has  only  compressed  them), — ^the  speech-centres, 
or  so  much  of  them  as  remains  undamaged,  may  gradually  resume  their  function ; 
whilst  the  subsidiary  speech-centres  in  the  opposite  side  of  the  brain  may,  by 
education,  undergo  development. 

The  degree  which  such  compensatory  activity  of  the  speech-centres  may  attain 
is  very  variable.  The  prognosis  is  best  in  children ;  under  the  age  of  five  or  six 
years,  provided  no  profound  dementia  be  present,  compensation  practically 
always  occurs,  and  the  aphasia  usually  clears  up  completely.  In  old  age,  on  the 
other  hand,  the  probabilities  of  re-education  of  subsidiary  speech-centres  are 
very  remote,  and  little  or  no  improvement  is  to  be  looked  for.  In  early  adult 
life,  or  middle  age,  individual  variations  are  so  great  that  an  accurate  prognosis 
in  any  particular  case  is  well-nigh  impossible.  Patients  with  word-deafness  are 
more  difficult  to  re-educate  than  those  with  word-blindness.  The  co-existence 
of  word-deafness  and  word-blindness  in  severe  degree  renders  re-education 
impossible,  while  the  absence  of  both  word-deafness  and  word-blindness,  as  in 
simple  motor  aphasia,  renders  the  prospects  relatively  much  more  favourable. 

Temporary  Aphasia.— A  transient  aphasia,  usually  slight  in  degree  and  evidenced 
mainly  by  a  difficulty  in  naming  objects,  may  arise  from  mere  debility  or  ex- 
haustion in  an  otherwise  healthy  person.  In  other  cases,  the  condition  is  due 
to  temporary  slowing  or  stasis  of  blood  in  diseased  cortical  arteries  ;  such  attacks 
are  to  be  regarded  as  warnings  of  threatened  thrombosis,  and  call  for  energetic 
treatment  of  the  arterial  disease,  especially  if  it  be  syphilitic  in  origin.  Temporary 
aphasia  also  occurs  from  localized  arterial  spasm,  the  patient  recovering  suddenly 
and  completely  within  a  few  hours.  We  also  meet  with  it  in  general  paralysis 
of  the  insane  as  part  of  a  '  congestive  attack.'  Certain  cases  of  migraine  are 
preceded  by  an  aura  of  temporary  aphasia,  usually  accompanied  by  a  subjective 
sensation  of  tingling  in  the  right  arm,  face  and  tongue,  and  followed  by  left-sided 
headache.  Aphasia  may  also  be  present,  for  a  short  time,  after  the  occurrence 
of  an  epileptic  fit,  doubtless  owing  to  temporary  cortical  exhaustion.  Lastly,  we 
may  have  temporary  aphasia  in  urajmia,  from  toxic  affection  of  the  speech- 
centres.  Purves  Stewart. 

APLASTIC  ANEMIA.— (See  Anemia,  Aplastic.) 
APOPLEXY.— (See  Strokes.) 

APPENDICITIS  :  Acute  and  Chrome. 

ACUTE  APPENDICITIS. 

Results  of  Operation. — In  the  year  1912,  936  cases  of  appendicitis  were 
admitted  to  the  London  Hospital.  Among  them  were  38  cases  which  for  one 
reason  or  another  were  not  operated  upon  ;  2  of  these  were  moribund  when 
they  were  admitted  and  died  shortly  aferwards.  I  have  excluded  these  38 
patients  and  completed  a  series  of  looo  cases  by  adding  102  others,  70  men  and 
32  women,  who  were  admitted  to  the  hospital  at  the  beginning  of  191 3. 


APPENDICITIS 


55 


Of  the  looo  cases,  698  were  operated  upon  during  the  attack,  302  during 
the  quiescent  stage.  Of  the  patients  who  were  operated  upon,  32  died,  which 
gives  a  mortaUty  in  all  cases  of  3'2  per  cent. 

Among  the  302  operations  performed  between  the  attacks  there  were  2 
deaths,  a  mortality  of  0-7  per  cent.  These  patients  were  suffering  from  actino- 
mycosis of  the  appendix  ;  death  was  due  in  both  cases  to  extension  of  the  disease, 
and  did  not  follow  immediately  upon  the  operation. 

I  have  divided  up  the  698  patients  who  were  operated  upon  during  the  acute 
stage  into  four  groups,  according  to  the  condition  found.  In  the  first  group  are 
placed  those  patients  who  had  general  peritonitis  ;  there  were  80  of  these,  16  of 
whom  died,  giving  a  mortality  of  20  per  cent.  In  the  second  group  are  211 
patients  who  had  an  abscess  ;  204  recovered  and  7  died,  giving  a  mortality 
of  3-3  per  cent.  In  the  third  group  are  those  who  had  local  peritonitis  only, 
including  those  cases  in  which  the  peritonitis  was  diffuse  but  did  not  involve  the 
whole  of  the  peritoneal  cavity  ;  these  numbered  123  with  6  deaths,  a  mortality 
of  4"8  per  cent.  Finally,  in  the  last  group  are  placed  those  patients  in  whom 
the  inflammation  was  limited  to  the  appendix  and  there  was  little  or  no 
evidence  of  local  peritonitis  ;  in  this  group  are  284  patients,  i  died,  a  mor- 
tality of  03  per  cent. 


Table  A. — Present  Mortality  in  Operations  for  Appendicitis. 


Total 

Recovered 

Died 

Mortality 

During  quiescent  stage 

302 

300 

2 

per  cent 
07 

During  acute  stage  : 
General  peritonitis    - 
Abscess            .            -            .            . 
Local    peritonitis 
Inflammation  localized  to  appendix 

80 
211 
12:5 

284 

64 
204 
117 
283 

16 
7 
6 
1 

20 

3"3 
4-8 

0-3 

Total 

698 

G68 

30 

4-3 

Grand  Total  (all  cases) 

1000 

968 

32 

3-2 

From  these  statistics  we  can  form  some  idea  as  to  the  prognosis  in  the  different 
forms  of  acute  appendicitis  if  the  patient  is  submitted  to  surgical  treatment  ; 
and  for  easy  reference  I  have  collected  them  together  in  Table  A .  It  is,  however. 
far  more  important  to  draw  attention  to  the  way  in  which  the  prognosis  varies 
according  to  the  time  at  which  operation  is  undertaken.  I  found  on  examining 
the  statistics  of  the  London  Hospital,  that  out  of  162  patients  who  were  operated 
upon  during  the  first  twenty-four  hours  of  an  attack,  only  2  died,  giving  a 
mortality  of  1-2  per  cent;  of  cases  operated  upon  during  the  second  twenty- 
four  hours  of  an  attack,  152  in  all,  6  died,  a  percentage  of  3-9  per  cent; 
whereas  of  those  in  whom  operation  was  postponed  until  the  third  day  of  the 
attack,  115  in  all,  10  died,  or  8-7  per  cent.  I  do  not  think  that  any  deductions 
can  be  drawn  from  the  death-rate  of  the  cases  operated  upon  from  the  fourth 
to  tjie  ninth  days,  as  the  numbers  are  so  small.  But  attention  may  be  drawn 
to  the  fact  that  of  the  58  patients  operated  upon  on  the  tenth  day  or  later, 
only  I  died.  If  Table  B  is  examined  for  details  of  these  cases,  it  will  be  seen 
that  40  were  cases  of  abscess  and  in  14  the  inflammation  was  limited  to  the 


56 


INDEX     OF     PROGNOSIS 


appendix;  in  other  words,  that  in  54  cases  the  condition  was  well  localized, 
consequently  there  was  much  less  danger  in  operating  upon  them  than  in  cases 
which  were  not  so  locahzed. 


Table    B. — Mortality    of   Operation    on    the   Different    Days 
OF  THE   Attack, 


Day 

Infleimed 

Local 
Peritonitis 

Abscess 

General 
Peritonitis 

Total 

R. 

D. 

R. 

D. 

R. 

D. 

R. 

D. 

1 

R. 

D. 

per  cent 

I  St  dav 

1)9 

1 

35 

0 

13 

0 

13 

160 

2 

1-2 

2nd  day 

62 

0 

39 

1 

2D 

1 

20 

4 

146 

6 

3' 

3rd  day 

40 

0 

10 

3 

43 

2 

12 

0 

105 

10 

8-7 

4th  day 

22 

0 

10 

1 

10 

0 

6 

1 

48 

2 

4 

5th  day 

12 

0 

3 

0 

17 

0 

3 

1 

35 

1 

2-8 

6  th  dav 

5 

0 

4 

0 

11 

0 

1 

0 

21 

0 

0 

7th  dav 

9 

0 

.    3 

0 

23 

1 

fi 

2 

41 

3 

6-8 

8th  day 

4 

0 

1 

0 

5 

0 

0 

0 

10 

0 

0 

qth  day 

2 

0 

1 

0 

5 

2 

1 

0 

9 

4 

30 

loth  dav    1 

or  later/ 

14 

0 

3 

1 

40 

0 

0 

0 

57 

1 

1-7 

Day  not    | 

stated    / 

14 

0 

8 

0 

12 

1 

0 

36 

1 

2-7 

Total 

283 

1 

117 

6 

204 

7 

64 

16 

668 

30 

4-3 

R   —  Recovered. 


These  statistics  illustrate  the  value  of  early  operation,  during  the  first  twenty- 
four  hours  of  the  attack  if  possible,  and  the  cases  are  sufficiently  numerous  to 
justify  the  statement  that  operation  during  the  first  twenty-four  hours  is  attended 
with  extremely  little  risk  ;  operation  during  the  second  day  with  considerably 
more  risk,  though  it  is  still  small ;  but  if  operation  is  postponed  until  the  third 
day,  the  prognosis  is  much  more  serious. 

Some  may  argue  that  the  results  obtained  in  the  operations  on  the  tenth  day 
or  later  are  strongly  in  favour  of  postponing  operation.  The  reply  of  course  is 
that  it  is  generally  impossible  to  tell  in  which  cases  the  inflammxatory  process 
will  become  localized  and  operation  may  be  deferred  with  safety.  I  would  once 
more  point  to  the  total  mortality  of  3-2  per  cent  in  this  series,  compared  with 
the  total  mortality  of  17-2  per  cent  in  another  series  of  1000  cases  which  I  collected 
in  1905  ;  at  that  time  operation  was  very  rarely  performed  in  the  first  stages 
of  the  attack,  but  was  postponed  as  long  as  possible  in  order  to  allow  the  attack 
to  subside,  or  failing  this,  to  allow  the  inflammation  to  become  locahzed. 

The  earlier  statistics  illustrate  the  results  of  postponing  operation,  the  present 
ones  the  result  of  operating  early. 

If  all  cases  could  be  left  with  safety  until  the  tenth  day,  the  general  mortality 
would  be  still  lower  than  it  is  ;  but  unfortunately  they  cannot,  and  it  is  therefore 
our  duty  to  remove  the  appendix  at  a  time  when  the  risk  is  reduced  to  a  minimum, 
that  is,  during  the  first  twenty-four  hours,  a  procedure  which  offers  the  prospect 
of  a  mortality  of  only  1-2  per  cent. 

Complications  of  Acute  Appendicitis. — Unfortunately  it  is  by  no  means  rare 
for  the  patient's  convalescence  to  be  delayed  by  certain  complications  which 
may  arise  during  the  attack.  Thus  we  find  that  out  of  698  patients  operated 
upon  during  the  acute  stage,  in  85,  that  is  I2'2  per  cent,  various  complications 
arose.      Among  them   were    25   cases  of  faecal  fistula,   22   cases  of   secondary 


APPENDICITIS 


57 


abscess,  17  pulmonary  complications,  and  12  cases  of  intestinal  obstruction;  3 
patients  had  more  than  one  complication ;  for  example,  of  two  of  the  cases  of 
pleural  effusion,  one  was  associated  with  a  subdiaphragmatic  abscess  and  the 
other  with  bronchopneumonia — and  the  patient  with  empyema  also  had  a 
subdiaphragmatic  abscess. 

That  12-2  per  cent  of  all  patients  operated  upon  during  an  attack  of  appen- 
dicitis, or  one  in  eight,  should  suffer  from  complications  is  very  unsatisfactory, 
but  even  so  it  is  a  great  improvement  on  former  results. 

The  explanation  of  this  improvement  is  easy ;  there  can  be  no  doubt  that  it 
is  due  to  operating  early  instead  of  postponing  it  until  the  patient  has  developed 
an  abscess  or  general  peritonitis.  For  on  investigating  the  85  cases  in  which 
complications  arose,  we  find  that  in  all  but  six  there  was  an  abscess  or  peritonitis, 
general  or  local  ;  in  the  great  majority  an  abscess  or  general  peritonitis.  Of  the 
6  cases  in  which  the  inflammation  remained  localized  to  the  appendix,  i  was 
a  case  of  intestinal  obstruction  in  which  the  appendix  itself  formed  the  obstructing 
band,  and  probably  became  gangrenous  in  consequence  of  the  cutting  off  of 
its  blood  supply  by  the  stretching  of  the  appendix  and  its  mesentery. 

Table  C. — Complications  which  Occurred  Amongst 

6g8    Cases    Operated    upon    During 

THE    Attack. 


Complications 

No.  of  Cases 

Secondary  abscess             - 
Subdiaphragmatic    abscess 

Faecal  fistula            .            .            -            -            - 
Thrombosis              -             -            -            -             - 
Pulmonary  complications  : 

(i)  Empyema           -            -            -             - 

(2)  Pleural  effusion 

(3)  Bronchopneumonia 

(4)  Lobar  pneumonia 

(5)  Bronchitis           .            -             -            - 
Intestinal  obstruction        .            .            .            - 
Pylephlebitis            .             .            -            .             - 
Cystitis         -             -                         .            .             . 
Haematemesis,  ha;maturia,  purpura 

22 
4 

2:") 
4 

1 
4 
7 
2 

3-17 

12 

2 

1 

1 

Total  number  of  complications 
Total  number  of  patients  affected 

88 

*85 

'One  of  the  patients  with  pleural  effusion  also  had  a  subdiaphragmatic 
abscess,  and  another  had  bronchopneumonia.  The  patient  with 
empyema  had  a  subdiaphraj^matic  abscess. 

Secondary  Abscess. — Secondary  abscesses  form  a  large  proportion  of  the 
complications,  for  as  will  be  seen  on  reference  to  Table  C,  a  secondary  abscess 
developed  in  no  less  than  22  of  the  85  patients,  apart  from  the  four  patients 
who  had  a  subdiaphragmatic  abscess.  The  majority  occurred  in  the  pelvis, 
in  the  rectovesical  pouch,  as  a  natural  consequence  of  the  routine  adoption  of 
the  valuable  Fowler's  position,  which  causes  all  free  fluid  in  the  peritoneal  cavity 
to  gravitate  to  the  pelvis. 

But  the  number  of  these  cases  of  secondary  abscess  is  unnecessarily  large,  for 
it  is  due,  I  think,  to  inadequate  drainage.  A  few  years  ago  there  was  a  tendency 
to  leave  drainage  tubes  in  too  long  ;  more  recently  the  pendulum  has  swung  to 
the  opposite  extreme,  and   drainage  is  not  continued  long  enough,  and  indeed 


58  INDEX     OF     PROGNOSIS 

in  some  cases  not  employed  where  it  is  necessary.  I  well  remember  my  disgust 
on  visiting  my  wards  one  afternoon,  to  iind  that  three  cases  of  acute  appendicitis, 
which  I  had  operated  on  a  few  days  previously,  had  each  developed  a  pelvic 
abscess,  thanks  to  a  misguided  enthusiasm  which  led  a  new  house  surgeon 
to  remove  prematurely  the  drainage  tubes  which  had  been  placed  in  the  recto- 
vesical pouch.  Fortunately  the  prognosis  is  good— none  of  the  cases  of  secondary 
abscess  proved  fatal. 

Subdiaphragmatic  Abscess. — A  subdiaphragmatic  abscess  occurred  4  times. 
In  I  case  it  was  associated  with  clear  fluid  in  the  right  pleura,  and  in  the  other 
cases  with  a  right  empyema.  All  four  occurred  in  old-standing  cases  ;  in  2  there 
was  general  peritonitis,  and  operation  was  not  performed  until  the  fifth  and 
sixth  days  of  the  attack  ;    in  2  there  was  an  abscess.     All  4  cases  recovered. 

These  results  are  unusually  good.  Hoffmann  quotes  Korte,  who  collected 
60  cases,  with  a  mortality  of  33-3  per  cent.  Barnard  collected  76  cases  :  40  lived 
and  36  died,  a  mortality  of  47-4  per  cent.  Of  these,  12  were  not  operated  on, 
and  they  all  died.  Of  the  64  who  underwent  operation,  24  died,  a  mortality 
of  37'5  per  cent.  But  of  the  21  consecutive  cases  operated  upon  by  Barnard 
himself,  only  17-7  per  cent  died,  a  proportion  which  is  a  truer  representation  of 
the  mortality  of  subdiaphragmatic  abscess  at  the  present  day.  This  is  largely 
due  to  the  pioneer  work  done  by  Barnard  in  this  direction,  and  also  to  further 
advances  in  our  methods  of  diagnosis  and  treatment. 

We  must  regard  a  subdiaphragmatic  abscess  as  a  serious  complication.  For 
although  the  four  cases  mentioned  above  all  recovered,  the  number  is  too  small 
to  justify  any  deductions  as  to  the  mortality  of  this  condition  ;  nevertheless  the 
fact  that  they  all  did  recover  is  encouraging.      [See  also  Subphrenic  Abscess.) 

Fescal  Fistula. — A  faecal  fistula  is  far  more  likely  to  occur  in  a  patient  who  is 
operated  upon  late  in  an  attack  than  in  one  who  has  been  operated  upon  within 
the  first  forty-eight  hours.     It  may  result  from  any  of  the  following  causes  : 

1.  Direct  extension  of  the  gangrenous  process  from  the  appendix  to  the  caecum 
or  ileum. 

2.  Imperfect  occlusion  of  the  appendix  stump.  This  may  occur  in  cases  in 
which  only  part  of  the  appendix  has  been  removed,  as  the  proximal  part  could 
not  be  discovered,  or  it  may  occur  in  those  cases  in  which  an  invaginating  purse- 
string  suture,  placed  in  the  wall  of  the  caecum  round  the  insertion  of  the 
appendix,  has  either  cut  through  the  inflamed  and  oedematous  tissue  or  given  way. 

3.  Actual  tearing  of  the  intestine  at  the  time  of  operation. 

4.  Patches  already  ulcerated  and  eroded,  which,  when  freed  from  the 
adhesions  which  support  them,  perforate. 

5.  The  pressure  of  a  drainage  tube  on  the  intestine.  In  cases  of  prolonged 
suppuration,  this  pressure,  combined  with  sepsis,  may  give  rise  to  ulceration 
of  the  intestine,    with  subsequent  formation  of  a  faecal  fistula. 

Most  of  these  fistulae  can  be  avoided  by  early  operation  ;  the  following  case 
may  be  given  as  an  example. 

About  two  years  ago  I  operated  upon  a  boy  of  18,  thirty-six  hours  after  the 
onset  of  the  attack.  The  appendix  was  gangrenous,  and  continuous  with  it  was 
a  gangrenous  patch  on  the  caecum  the  size  of  a  five-shilling  piece.  The  appendix 
was  removed,  the  gangrenous  part  of  the  caecum  invaginated,  and  the  patient 
made  a  rapid  and  uninterrupted  recovery.  If  an  early  operation  had  not  been 
undertaken,  a  faecal  fistula  would  have  been  inevitable. 

Of  the  25  cases  of  faecal  fistula,  there  were  only  4  in  which  the  operation  was 
performed  within  the  first  forty-eight  hours.  In  the  great  majority  of  cases 
the  faecal  fistula  followed  an  old-standing  abscess.  In  the  present  series, 
faecal  fistula  occurred  25  times  in  698  acute  cases,  or  3-6  per  cent. 


APPENDICITIS  59 


As  regards  prognosis,  it  appears,  therefore,  that  in  acute  cases  3-6  per  cent  of 
patients  will  develop  a  faecal  fistula.  If,-  however,  the  operation  is  undertaken 
within  the  first  twenty-four  hours,  or  even  the  first  forty-eight  hours  the  chances 
of  a  fistula  forming  are  so  slight  as  to  be  negligible.  Of  the  25  patients  with 
faecal  fistula,  3  died. 

With  regard  to  the  fistula  itself,  as  a  rule  it  closes  spontaneously,  in  the 
majority  of  cases  within  fourteen  days.  It  is  rarely  necessary  to  operate,  but 
if  the  fistula  persists,  the  question  of  operation  must  be  considered. 

Thrombosis. — This  is  another  complication  which  is  met  with  less  frequently 
than  formerly.  Thrombosis  of  the  femoral  veins  occurred  4  times,  twice  on 
the  right  side  and  twice  on  the  left. 

The  symptoms  usually  occur  from  two  to  three  weeks  after  the  beginning  of  the 
illness.  There  is  first  a  slight  rise  of  temperature,  the  following  day  a  little  pain 
in  the  affected  limb  along  the  course  of  the  vein,  with  probably  slight  cedema 
of  the  foot,  and  the  next  day  the  oedema  becomes  more  marked. 

The  first  case  was  that  of  a  boy  with  a  retrocaecal  abscess,  who  had  been  ill 
for  five  days  before  his  admission  to  the  hospital  ;  the  second  case,  a  man  of 
45,  had  an  abscess  and  had  been  ill  for  ten  days  ;  in  the  third  case,  a  man  of  53, 
there  was  no  abscess,  but  the  operation  was  a  difficult  one  and  there  were  many 
adhesions.  The  fourth  case  was  a  man  of  65,  who  had  general  peritonitis  with 
a  gangrenous  appendix,  and  who  had  only  been  ill  for  a  day  and  a  half.  In  the 
latter  case  there  is  little  doubt  that  the  age  of  the  patient  and  his  feeble  circu- 
lation predisposed  to  thrombosis.     All  four  patients  recovered. 

In  considering  the  prospect  of  a  case  of  femoral  thrombosis,  one  must  remember 
the  danger  of  its  giving  rise  to  pulmonary  embolism,  and  bear  in  mind  Hoffmann's 
statement  that  out  of  39  patients  who  had  femoral  thrombosis,  pulmonary 
embolism  occurred  in  22. 

The  ultimate  prognosis  of  thrombosis  of  the  femoral  veins  is  good  in  young 
subjects,  although  the  leg  will  probably  remain  cedematous  for  many  months. 
Wearing  an  elastic  bandage,  and  massage  after  a  due  interval,  cause  great 
improvement. 

Pulmonary  Embolism. — In  connection  with  thrombosis  we  must  consider  the 
extremely  important  condition  of  pulmonary  embolism.  In  4000  cases  of 
appendicitis,  Hoffmann  reported  39  cases  of  thrombosis  of  the  femoral  veins, 
and  no  less  than  22  of  these  gave  rise  to  pulmonary  embolism,  18  of  the  22  cases 
proving  fatal.  McWilliam,  in  685  acute  cases,  found  4  cases  of  pulmonary 
embolism,  of  whom  3  died  on  the  third,  ninth,  and  tenth  days.  If  we  take 
these  two  reports  together,  we  see  that  out  of  26  cases,  21  died,  a  mortality  of 
8o-8  per  cent. 

Garre  and  Quincke  allude  to  the  varying  mortality  of  pulmonary  embolism 
in  the  statistics  of  different  authors.     They  quote  the  following  : — 

Lotheissen  found  52  deaths  out  of  61  cases  =  83-3  per  cent. 

Albanus             ..  10         ,,         ,,         23,,  =:  43"5 

Gebele               .  .  11          ,,          ,,         14     ,,  --  79            ,, 

Wyder                ..  S          ,,          ,,          12     ,,  =-66 

The  difference  is  probably  due  to  the  inclusion  of  slight  cases  by  some  authors, 
while  others  only  included  cases  in  which  the  symptoms  were  pronounced  and 
severe. 

Pulmonary  embolism  is,  perhaps,  the  greatest  tragedy  of  surgery,  and  any 
treatment  which  is  likely  to  prevent  this  calamity  should  receive  most  careful 
attention.  Hoffmann  has  obtained  remarkable  results  by  making  the  patient 
stand  up  out  of  bed,  even  if  only  for  a  minute,  the  day  after  operation,  and  this 


6o  INDEX     OF     PROGNOSIS 

is  repeated  on  subsequent  days.  If  it  is  quite  impossible  for  the  patient  to  stand, 
passive  and  active  movements  of  the  lower  extremities  are  instituted  and,  later, 
massage.  His  statistics  embrace  all  cases  up  to  the  3'ear  1912,  and  this  treatment 
was  begun  in  the  year  1908.  After  the  introduction  of  this  treatment  there  were 
only  3  cases  of  thrombosis  and  emboli,  compared  with  36  in  the  previous 
years,  and  none  of  these  three  had  been  made  to  get  out  of  bed  the  day  after 
operation.  This  is  most  suggestive,  and  the  treatment  is  worthy  of  very  careful 
consideration. 

The  mortality  of  severe  cases  of  pulmonary  embolism  appears  to  be  about 
75  per  cent,  but  as  was  pointed  out  by  Sir  Douglas  Powell,  in  all  probability 
many  of  the  cases  of  bronchopneumonia,  empyema,  and  pleurisy,  which  arise 
as  complications  of  appendicitis,  are  really  embolic  in  origin.  Fortunately, 
we  can  say  that  at  the  present  time,  with  modern  methods  of  treatment,  fatal 
pulmonary  embolism  is  an  extremely  rare  complication  of  appendicitis. 

In  4  cases  the  pulmonary  artery  has  been  opened  and  the  clot  removed  by 
Trendelenburg's  operation.  The  most  successful  case  was  a  woman  operated 
upon  by  Kriiger  ;  she  lived  for  five  days  and  a  quarter  after  the  operation,  and 
died  from  purulent  pleurisy. 

Other  Pulmonary  Complications. — Pulmonary  affections  form  a  large  propor- 
tion of  the  total  number  of  the  complications,  viz.,  17  out  of  a  total  of  88. 
Reference  to  Table  C  will  show  the  relative  frequency  of  the  different  conditions, 
bronchopneumonia  heading  the  list,  and  pleural  effusion  coming  second. 

Empyema  only  occurred  once,  and  then  was  in  association  with  a  sub- 
diaphragmatic abscess. 

Pleural  effusion  occurred  in  4  cases.  In  one,  the  patient  had  been  lH  three 
weeks  and  had  a  subdiaphragmatic  abscess.  The  second  patient  was  operated 
upon  for  general  peritonitis  on  the  third  day  of  the  attack,  and  developed  double 
pleurisj'  and  bronchopneumonia.  Both  of  the  other  two  patients  had  local 
peritonitis,  and  the  fluid  was  on  the  right  side  of  the  chest. 

In  the  8  other  cases  of  bronchopneumonia  and  lobar  pneumonia  there  was 
an  abscess  or  peritonitis  in  6.  Bronchopneumonia  developed  in  one  case  of 
acute  appendicitis  in  which  the  inflammation  was  limited  to  the  appendix  ; 
and  in  another  similar  case,  in  which  there  were  adhesions  and  free  fluid  in  the 
peritoneal  cavity,  the  patient  had  right  lobar  pneumonia. 

A  patient  of  64,  who  had  a  perforated  appendix  and  was  operated  upon 
four  days  after  the  beginning  of  the  attack,  died  from  bronchitis  and  heart 
failure. 

These  results  are  striking  evidence  of  the  relation  between  late  operation  and 
pulmonary  complications,  and  indicate  the  prophj-lactic  value  of  operation 
during  the  first  twenty-four  hours  of  the  attack. 

Intestinal  Obstruction. — Intestinal  obstruction  is  a  grave  and  not  uncommon 
complication  of  appendicitis.  I  find  that  it  occurred  12  times,  that  is,  in  1-2 
per  cent  of  all  cases,  or  in  1-7  per  cent  of  the  acute  cases. 

The  obstruction  may  be  either  paralytic  or  mechanical.  In  the  paralytic 
variety  or  ileus,  there  is  paralysis  of  the  intestine  with  resulting  symptoms  of 
intestinal  obstruction.  In  my  present  series  there  were  5  exam.ples  of  this 
condition,  and  4  of  them  died.  In  its  milder  forms  it  is  commonly  met  with, 
and  therefore  it  is  possible  to  assume  that  there  were  other  cases  in  which  ileus 
was  present  to  a  slight  degree  but  no  mention  has  been  made  of  it.  WTien  ileus 
occurs  in  an  attack  of  appendicitis  it  is  alwaj^s  of  grave  prognosis,  but  less  so 
when  it  occurs  early  in  an  attack  than  later.  In  the  former  condition,  particu- 
larly when  it  is  present  before  operation,  it  is  often  possible  to  overcome  it  by 
appropriate  treatment ;    but  when  it  occurs  in  the  later  stages,  the  prognosis  is 


APPENDICITIS  6i 


very  grave.     Much  can  be  done  to  relieve  the  patient  by  turpentine  enemata 

and  the  hypodermic  administration  of  eserine  in  yj-^  gr.  doses  every  six  hours, 
which  may  be  combined  with  hypodermic  injections,  of  strychnine. 

Mechanical  obstruction  occurred  in  7  cases,  of  which  5  recovered  and  2 
died.  It  may  be  due  to  the  presence  of  adhesions,  producing  a  kink  in  a  piece 
of  intestine,  or  adhesions  may  take  the  form  of  a  band,  which  may  form  a 
loop  round  a  piece  of  intestine  and  so  ensnare  it  ;  or  a  loop  of  intestine  may 
pass  underneath  the  band  and  become  strangulated  in  that  way.  Lastly,  the 
appendix  itself  is  not  very  uncommonly  the  immediate  cause  of  intestinal 
obstruction.  I  recently  operated  upon  a  patient  in  whom  the  tip  of  the  appendix 
was  adherent  to  the  root  of  the  mesentery  ;  it  had  formed  a  loop,  and  through 
this  loop  a  piece  of  intestine  had  passed  and  was  tightly  gripped.  Not  only  was 
the  intestine  gangrenous,  but  also  the  appendix  itself.  When  the  appendix 
forms  the  constricting  band,  the  prognosis  becomes  rather  n\ore  serious,  as  not 
infrequently  the  stretching  of  the  appendix  has  cut  off  its  blood-supply,  and 
gangrene  has  followed,  with  resulting  general  peritonitis.  In  these  cases  the 
primary  condition  appears  to  be  that  of  intestinal  obstruction,  with  secondary 
gangrene  of  the  appendix. 

Ruge  found  44  cases  of  intestinal  obstruction  in  2,385  cases  of  appendicitis, 
a  proportion  of  i-8  per  cent,  which  is  not  very  far  from  the  proportion  of  1-2  per 
cent  in  my  cases.  Among  these  44,  there  were  14  cases  of  ileus,  7  of  which 
recovered  and  7  died.  In  the  other  cases,  the  appendix  itself  formed  the  constric- 
ting band  in  no  less  than  6  ;   of  these  only  2  recovered,  and  4  died. 

The  frequency  with  which  intestinal  obstruction  occurs  depends  largely  on  the 
time  at  which  the  primary  operation  is  performed,  as  is  the  case  with  nearly  all 
the  other  complications  of  appendicitis.  It  is  interesting  to  note  that  in  all  of 
my  12  cases  either  an  abscess  or  general  peritonitis  existed.  None  of  these  cases 
had  been  submitted  to  what  is  known  as  early  operation,  that  is,  within  the  first 
twenty-four  hours,  or  even  the  first  forty-eight  hours.  The  real  secret  of 
successful  treatment  of  intestinal  obstruction  in  appendicitis  is  to  prevent  its 
occurrence. 

The  prognosis  is  grave.  Out  of  the  12  cases  in  the  present  series,  6  recovered 
and  6  died,  while  out  of  Ruge's  cases  23  recovered  and  21  died — a  total  of  29 
recoveries  and  27  deaths,  giving  the  high  mortality  of  48-2  per  cent. 

In  discussing  intestinal  obstruction  due  to  appendicitis,  one  must  bear  in  mind 
the  possibility  of  an  attack  of  appendicitis  leaving  behind  it  bands  and  adhesions, 
which  may  cause  intestinal  obstruction  at  a  later  date. 

Jaundice. — Speaking  generally,  whan  jaundice  complicates  an  attack  of 
appendicitis,  the  prognosis  is  grave. 

Hoffmann  has  recorded  11  cases  ;  in  nearly  all  of  them  there  was  acute 
perforative  appendicitis  ;  in  several,  diffuse  peritonitis  or  extensive  abscesses. 
He  regards  jaundice  as  a  sign  of  very  severe  illness,  especially  if  it  appears  early 
in  the  attack. 

Reichel  thinks  that  jaundice  may  arise  from  the  spreading  of  infectious  material, 
and  therefore  advises  that  in  the  case  of  an  abscess,  one  should  be  content  with 
opening  it  and  nothing  more,  when  the  disease  has  existed  forty-eight  hours. 
Eight  of  his  18  patients  who  had  jaundice  recovered — a  mortality  of  55-55  per 
cent ;   but  of  Aldehoff's  14  cases,  11  recovered  and  only  3  died. 

Jaundice  may  be  due  to  various  causes  and  may  appear  at  various  stages  of 
the  illness.  The  following  are  the  principal  causes  : — (i)  Simple  catarrhal 
jaundice  ;  (2)  Toxaemia  ;  (3)  Direct  extension  of  the  inflammation  from  the 
appendix  to  the  gall-bladder  and  biliary  ducts  ;  (4)  Pylephlebitis  ;  (5)  The 
so-called  delayed  chloroform  poisoning. 


62  INDEX     OF     PROGNOSIS 

1.  Simple  Catarrhal  Jaundice. — I  recently  saw  a  case  of  this  sort  in  Avhich 
the  patient's  illness  began  with  vomiting  ;  catarrhal  jaundice  shortly  followed, 
and  next  day  pain  began  in  the  right  iliac  fossa.  Operation  was  performed 
within  thirty-six  hours  and  an  acutely  inflamed  appendix  removed.  The 
jaundice  followed  the  usual  course  of  catarrhal  jaundice  and  subsided  in  the 
usual  way,  after  a  brief  period  in  which  the  stools  were  clay-coloured,  the  urine 
contained  large  quantities  of  bile  pigment,  and  the  skin  and  sclerotics  were  deeply 
tinged  with  yellow.  This  is  the  least  serious  form,  and  may  be  met  with  in 
varying  degrees  ;  in  some  cases  there  is  merely  a  slight  and  evanescent  tingeing 
of  the  sclerotics,  but  in  others,  as  in  the  case  just  described,  the  patient  may 
pass  through  a  typical  attack  of  catarrhal  jaundice. 

2.  Toxcsniia. — -The  second  class  consists  of  cases  in  which  the  jaundice  appears 
to  be  the  result  of  toxaemia.  A  good  example  of  this  kind  has  been  described 
by  Hollander.  The  patient  had  well-marked  jaundice  with  an  appendix  abscess. 
The  abscess  was  opened  and  drained,  and  a  gangrenous  appendix  removed.  The 
jaundice  disappeared  within  two  or  three  days.  In  consequence  of  his  experience 
in  this  case,  Hollander  suggests  that  when  jaundice^ is  present  in  cases  of  acute 
appendicitis,  it  indicates  that  the  appendix  is  gangrenous.  There  are  also  mild 
cases  in  which  the  jaundice  appears  in  the  early  stages  of  the  attack  and  passes 
off  shortly  after  operation  ;    they  probably  belong  to  this  class  also. 

3.  In  the  third  class  are  placed  cases  in  which  there  is  a  direct  extension  of 
inflammation  of  the  appendix  to  the  gall-bladder,  and  numerous  adhesions  are 
found  about  the  gall-bladder. 

4.  Pylephlebitis.- — -The  fourth  class  is  composed  of  cases  which  are  still  more 
serious.  I  refer  to  those  in  which  the  jaundice  is  due  to  portal  pyaemia  or  acute 
pylephlebitis.  These  cases  are  fortunately  rare.  In  the  1000  cases  which  I 
collected  in  1905,  there  were  4  of  pylephlebitis,  all  of  which  died.  In  the 
present  series  there  were  2  cases,  one  of  which  was  due  to  actinomycosis. 

It  is,  however,  important  to  remember  that  jaundice  is  not  alwa^'s  present  in 
these  cases.  In  neither  of  the  2  reported  by  Bidwell,  one  of  which  recovered, 
was  there  jaundice. 

The  diagnosis  of  the  condition  is  generally  easy.  The  usual  history  is  that  of 
an  attack  of  acute  appendicitis,  the  formation  of  an  abscess,  and  after  a  varying 
interval,  the  onset  of  rigors,  and  a  few  days  later,  the  appearance  of  jaundice. 
A  little  later  still,  the  Hver  maj'-  enlarge  and  become  tender.  It  is  interesting  to 
note,  however,  that  this  is  by  no  means  invariably  the  sequence  of  events.  I 
remember  a  patient  who  was,  some  years  ago,  in  the  London  Hospital  under  my 
care  with  jaundice,  enlargement  of  the  liver,  and  tenderness  in  the  region  of  the 
gall-bladder.  There  was  a  history  of  an  acute  attack  of  pain  on  the  right  side  of 
the  abdomen  three  weeks  previously  ;  the  temperature  was  raised.  A  diagnosis 
was  made  of  acute  cholangitis  secondary  to  gall-stones  ;  but  operation  proved 
that  the  patient  had  pylephlebitis  with  a  small  retrocaecal  abscess  and  a  perforated 
appendix. 

I  have  been  rather  struck,  in  the  few  cases  which  I  have  met  with,  by  the 
comparatively  mild  local  signs  of  appendicitis  ;  but  this  cannot  be  taken  as  the 
rule,  for  in  7  cases  reported  by  Hoffmann,  2  followed  acute  appendicitis,  3 
after  incising  an  abscess,  and  2  after  operation  for  diffuse  peritonitis.  Sasse, 
however,  reports  2  cases  in  which  the  appendicitis  was  of  such  a  mild  t^'pe 
that  the  patients  were  not  confined  to  bed  ;  but  about  ten  days  after  the 
beginning  of  the  attack  they  developed  symptoms  of  pylephlebitis,  and  died  a  few 
days  later.  The  gravity  of  the  condition  Ues  in  the  fact  that,  as  a  rule,  the  liver  is 
riddled  with  smaU  abscesses,  and  so  is  beyond  surgical  treatment.  Of  Hoffmann's 
7  cases,  in  only  2  was  there   an  abscess  sufiQciently  large  to  be  incised  ;    one 


APPENDICITIS  63 


of  these  recovered,  but  the  other  patient  died.  In  my  own  experience  I  have 
had  2  cases  which  recovered,  one  of  them  a  patient  with  a  large  abscess,  which 
was  drained,  and  the  other  a  case  of  considerable  interest,  in  which,  on  exposing 
the  liver,  I  found  numerous  small  abscesses  the  size  of  a  pea  or  less  ;  the  Staphylo- 
coccus pyogenes  aureus  was  found  in  pure  culture,  a  vaccine  was  prepared,  and 
the  patient  made  a  good  recovery. 

While  the  prognosis  in  cases  of  pylephlebitis  is  necessarily  grave,  it  is  not 
hopeless  ;  an  exploratory  operation  should  be  performed,  and  the  condition 
found  dealt  with  by  drainage  where  possible,  otherwise  by  vaccines.  It  goes 
without  saying  that  in  these  cases  the  primary  focus  of  the  disease,  namely, 
the  appendix,  should  always  be  removed. 

With  regard  to  prophylactic  treatment,  Wilms  has  published  a  very  remark- 
able case  in  which  he  ligatured  the  efferent  veins  leading  from  the  appendix. 
This  patient  had  had  five  rigors ;  but  after  the  veins  were  ligatured  the  rigors 
ceased  and  the  patient  made  a  good  recovery,  without  gangrene  of  the  intestine 
or  any  interference  with  peristalsis.  Sprengel  attempted  to  carry  out  a  similar 
operation  in  a  patient  upon  whom  he  had  operated  and  from  whom  he  had 
removed  a  gangrenous  appendix  thirty-six  hours  after  the  beginning  of  the 
attack.  Nine  days  after  removal  of  the  appendix  the  patient  had  a  rigor  and, 
subsequently,  two  or  three  every  day.  Sprengel's  attempts  at  ligature  were 
unsuccessful,  and  a  faecal  fistula  developed  at  the  lower  end  of  the  small  intestine, 
probably  due  to  gangrene  through  interference  with  the  circulation.  As  he 
points  out,  the  operation  is  likely  to  be  difficult  enough  in  a  normal  subject  in 
the  absence  of  inflammation,  if  there  is  no  mesentery  to  the  colon,  and  where 
there  is  a  large  amount  of  subserous  fat ;  but  if,  in  addition,  the  structures  round 
the  appendix  are  acutely  inflamed,  it  becomes  almost  impossible  to  isolate  the 
veins  ;  and  even  if  the  veins  are  secured,  the  danger  of  ligaturing  the  arteries  as 
well,  and  so  giving  rise  to  gangrene,  is  very  great. 

5.  Delayed  Chloroform  Poisoning. — In  the  last  class  I  would  place  cases  of 
so-called  delayed  chloroform  poisoning.  This  most  distressing  condition  I  have 
met  with  in  varying  degrees  on  several  occasions,  but  fortunately  have  only  lost 
one  patient  through  it.  This  was  a  considerable  number  of  years  ago,  shortly 
after  attention  had  first  been  drawn  to  the  disease. 

The  patient  was  a  little  girl  of  eleven,  upon  whom  I  operated  and  removed  an 
inflamed  appendix  within  thirty-six  hours  of  the  onset  of  the  attack.  Chloro- 
form was  given  and  the  operation  was  straightforward,  but  twenty-four  hours 
afterwards  she  began  to  vomit.  The  vomit  at  first  consisted  of  ordinary  gastric 
contents,  but  later  it  contained  altered  blood  and  became  cofiee-ground  in 
character.  With  the  onset  of  vomiting  her  mental  condition  became  a  httle 
clouded  ;  later  she  became  delirious  and,  finally,  comatose.  Jaundice  set  in  thirty- 
six  hours  after  the  operation,  and  at  the  end  of  forty-eight  hours  was  well  marked  ; 
it  was  not  limited  merely  to  the  sclerotics,  but  extended  over  the  whole  body. 
The  breath  smelt  strongly  of  acetone,  the  temperature  was  slightly  raised,  the 
pulse-rate  steadily  increased  in  rapidity  and  became  proportionately  weaker  ; 
the  respirations  towards  the  end  were  irregular  and  approximated  to  the  Cheyne- 
Stokes  rhythm.  The  abdominal  condition  appeared  to  be  entirely  satisfactory  ; 
the  abdomen  moved  well  on  respiration,  was  soft,  and  there  was  no  distention. 
She  died  sixty-four  hours  after  the  operation. 

This  was  a  typical  case  of  so-called  delayed  chloroform  poisoning.  The  first 
symptom  is  usually  vomiting,  which  comes  on  for  no  obvious  reason  about 
thirty-six  hours  after  the  operation,  and  the  case  is  frequently  fatal  within  forty- 
eight  hours  from  the  onset  of  the  vomiting.  I  must,  however,  point  out  that 
jaundice  is  not  present  in  all  these  cases. 


64  INDEX     OF     PROGNOSIS 

It  is  not  necessary  to  enter  here  into  the  various  theories.  Guthrie,  however, 
says  that  children  who  suffer  from  cychcal  vomiting  are  particularly  liable  to  be 
victims  of  post-anaesthetic  poisoning,  and  that  the  administration  of  an  anaesthetic 
on  the  eve,  or  during  an  attack,  of  cyclical  vomiting  is  attended  by  grave  risk, 
and  should  be  avoided  if  possible.  With  regard  to  prophylaxis,  it  is  particularly 
important  in  the  case  of  children  not  to  starve  them,  and  not  to  purge  them  too 
violently  before  the  operation.  Dextrose  and  soda  bicarbonate  should  be  given 
before  and  after  the  operation.  With  regard  to  the  prognosis  in  these  cases,  many 
of  them  recover  after  prompt  treatment  by  the  administration  of  large  quantities 
of  dextrose  and  soda  bicarbonate,  and  the  mortality  is  far  less  now  than  it  was 
before  attention  had  been  drawn  to  the  condition  and  the  proper  treatment 
realized. 

Pylephlehitis . — This  has  been  discussed  at  sufficient  length  in  class  4,  above. 
Apart  from  a  case  of  actinomycosis,  there  was  only  one  case  in  the  present 
series,  and  this  fortunately  recovered.  Jaundice,  although  present  in  a  certain 
number  of  cases,  is  not  necessarily  a  feature  of  pylephlebitis. 

Gastro-intestinal  Hcemorrhage. — Melaena  or  haematemesis  occurring  in  a  patient 
suffering  from  acute  appendicitis  is  a  matter  of  grave  importance,  all  the  more  so 
as  in  the  majority  of  cases  it  is  impossible  to  relieve  the  condition  by  surgical 
methods.  In  some  cases  the  haemorrhage  comes  from  a  duodenal  ulcer,  in  others 
from  the  stomach,  either  from  a  gastric  ulcer  or  from  numerous  small  erosions  ; 
in  other  cases,  again,  it  may  be  impossible  to  say  where  it  comes  from,  even  on 
post-mortem  examination. 

About  twelve  months  ago  I  operated  on  a  patient  who  was  suffering  from  an 
attack  of  appendicitis  with  a  large  pelvic  abscess.  He  had  been  ill  for  two  weeks. 
At  the  operation  I  removed  the  appendix  and  drained  the  abscess.  All  went 
well  until  five  days  after  the  operation,  when  he  suddenly  collapsed  ;  his  face 
became  blanched  and  his  pulse  almost  imperceptible.  He  improved  under 
appropriate  treatment,  and  shortly  afterwards  passed  an  offensive  motion 
containing  a  very  large  quantity  of  altered  blood  ;  during  the  subsequent  week 
he  had  several  similar  attacks,  though  less  severe.  All  this  time  he  had  melaena,  ■ 
frequently  three  or  four  motions  in  the  twenty-four  hours.  The  question  of 
operation  was  raised,  but  negatived,  as  his  condition  was  such  that  any  operative 
interference  would  almost  certainly  have  proved  fatal,  apart  from  the  fact 
that  it  was  impossible  to  decide  the  source  of  the  haemorrhage.  Fortunately 
it  gradually  ceased,  and  he  ultimately  made  an  excellent  recovery. 

Hoffmann  reported  7  cases  of  severe  gastro-intestinal  haemorrhage.  In  3  patients 
there  was  general  peritonitis  at  the  time  of  operation,  in  i  there  was  an  abscess, 
and  the  other  3  were  operated  upon  at  an  earlier  stage.  Only  one  patient 
recovered ;  of  the  other  6  cases,  in  2  the  haemorrhage  came  from  a  recent 
gastric  ulcer ;  in  another  there  was  serious  erosion  of  the  gastric  mucosa  ; 
in  a  third  the  post-mortem  showed  no  cause  for  the  severe  haemorrhage  ; 
one  patient  died  from  haemorrhage  in  a  few  hours,  seven  days  after  a  smooth 
appendicectomy  in  the  acute  stage — there  was  no  post-mortem  examination  ; 
the  seventh  case  was  a  boy  who  was  making  a  straightforward  recovery 
from  general  peritonitis,  and  died  suddenly  from  severe  haemorrhage — the  post- 
mortem examination  revealed  a  duodenal  ulcer,  with  erosion  of  the  splenic  artery. 

In  1908  Schwalbach  collected  28  cases  of  gastro-intestinal  haemorrhage  after 
operations  for  appendicitis,  and  added  2  of  his  own  ;  17  patients  died  and 
13  recovered.  The  mortality  in  his  series  was  directly  proportionate  to  the 
severity  of  the  appendicitis  :  9  patients  had  diffuse  peritonitis — they  all  died ; 
8  patients  had  an  abscess  with  localized  peritonitis — 5  died  and  3  recovered  ; 
6  patients    had    acute    appendicitis   with    only   slight    peritonitis — 3   died  and 


APPENDICITIS  ■        65 


3  recovered ;  7  patients  were  operated  upon  during  the  quiescent  period — these 
all   recovered.     One-third    of   the    cases    occurred   in    children. 

Schwalbach  thinks  that  the  haemorrhage  is  the  result  of  thrombosis  in  the 
venous  and  arterial  circulation  in  the  omentum  and  mesentery. 

Fortunately  this  is  a  rare  complication  ;  it  only  occurred  once  in  my  present 
series  of  cases,  and  the  patient  recovered.  If,  however,  a  patient  who  has  been 
operated  upon  for  acute  appendicitis  has  an  attack  of  gastro-intestinal  hsemor- 
rhage,  the  prognosis  becomes  grave  in  direct  proportion  to  the  severity  of  the 
appendicitis. 

In  most  cases,  surgical  intervention  is  contra-indicated  ;  treatment  should  be 
carried  out  on  medical  lines. 

Hcematuria. — Haematuria  is  a  rare  but  interesting  complication  of  appendicitis, 
and  its  pathology  is  still  somewhat  obscure.  Slight  haematuria  may  be  caused 
by  the  rupture  of  an  appendix  abscess  into  the  bladder,  but  the  amount  of  blood 
is,  as  a  rule,  very  slight,  and  there  is  but  little  difficulty  in  making  the  diagnosis. 
On  the  other  hand,  a  number  of  cases  have  been  reported  in  which  haematuria 
occurred  on  several  occasions  after  an  attack  of  pain  in  the  right  side  of  the 
abdomen,  and  the  condition  was  supposed  to  be  one  of  renal  colic.  It  was  only 
later,  when  symptoms  of  appendicitis  definitely  declared  themselves,  that  the 
true  diagnosis  was  made,  and  the  patient  was  cured  by  removal  of  the  appendix. 

Cases  of  haematuria  in  appendicitis  may  be  roughly  divided  up  into  two  main 
groups.  In  the  first  may  be  placed  those  cases  in  which  the  appendix  does  not 
lie  in  contact  with  any  part  of  the  genito-urinary  tract,  and  in  the  second,  those 
in  which  the  diseased  appendix  is  actually  in  contact  with  the  kidney,  ureter 
or  bladder.  In  6  out  of  15  cases  discussed  by  von  Frisch,  the  appendix  was 
adherent  to  the  lower  part  of  the  ureter. 

As  a  general  rule,  the  haematuria  follows  an  attack  of  pain  in  the  right  side  of 
the  abdomen,  and  in  a  few  cases  the  colic  and  haematuria  are  brought  on  by 
violent  exercise.     Occasionally  the  haematuria  is  preceded  by  little  or  no  pain. 

The  following  case  described  by  Hammersley  is  fairly  typical.  A  lady  had 
attacks  of  vomiting  with  shivering  and  colic,  every  three  months.  Two  days 
after  the  beginning  of  each  attack,  blood  appeared  in  the  urine,  and  on  one 
occasion  the  urine  appeared  to  be  almost  pure  blood.  The  attacks  were  brought 
on  by  unusual  bodily  exertion.  On  examination,  nothing  abnormal  could  be 
detected,  apart  from  a  movable  right  kidney  ;  the  kidney  was  not  painful  or 
enlarged.  There  was  no  tenderness  in  the  appendix  region.  Ultimately  an 
attack  occurred  which  was  associated  with  a  rise  of  temperature,  and  tenderness 
in  the  right  iliac  fossa  was  present  for  the  first  time.  The  appendix  was  removed, 
and  was  found  to  be  lying  behind  the  caecum,  adherent  to  the  right  kidney  and 
ascending  colon.     The  patient  had  no  further  attacks  of  colic  or  haematuria. 

A  somewhat  similar  case  in  which  the  colic  and  haematuria  followed  exertion 
has  been  described  by  von  Frisch. 

Another  remarkable  case  has  been  reported  by  Carless.  A  woman  had  typical 
attacks  of  renal  colic,  with  a  history  of  previous, severe  pain  in  the  right  side. 
She  was  relieved  after  the  passage  of  blood  in  the  urine  and  a  little  gravel.  The 
kidney  and  ureter  were  explored  with  a  negative  result.  A  week  later  the 
patient  died  from  a  perityphlitic  abscess.  The  post-mortem  examination 
showed  that  the  appendix  was  lying  on  the  back  of  the  abdomen  and  hanging 
down  over  the  pelvic  brim  in  the  region  of  the  ureter. 

In  other  cases,  as  in  a  boy  under  my  care  some  years  ago,  haematuria  may 
supervene  without  any  severe  attack  of  pain.  I  saw  my  patient,  a  boy  of  twelve, 
during  his  second  attack  of  haematuria.  No  tenderness  was  to  be  made  out  on 
abdominal  examination  ;    the  kidney  was  not  enlarged  ;    there  was  no  rise  of 

5 


66  INDEX     OF     PROGNOSIS 

temperature.  On  examination  with  the  cystoscope,  blood  was  seen  coming 
from  the  orifice  of  the  right  ureter.  On  examination  of  the  urine,  the  Bacillus 
coli  communis  was  found  in  pure  culture.  The  hsematuria  rapidly  subsided. 
Two  months  later  I  operated  upon  him  for  what  was  supposed  to  be  his  first 
attack  of  appendicitis  ;  but  on  removing  the  appendix  I  found  it  to  be  the  seat 
of  old-standing  disease.  In  this  case  the  appendix  was  not  in  contact  with  the 
kidney,  ureter,  or  bladder.  The  patient  remained  well  and  had  no  further 
haematuria. 

It  is  interesting  to  note  that  in  the  majority  of  cases  nothing  abnormal  is  to  be 
found  in  the  urine  apart  from  the  blood.  This  is  found  in  varying  quantities, 
and  it  is  not  uncommon  to  find  blood-casts  in  addition  to  altered  blood  corpuscles. 
The  most  striking  feature  of  the  condition,  however,  is  the  way  in  which  the 
hsematuria  clears  up  after  removal  of  the  appendix,  and  does  not  recur. 

As  for  the  explanation  of  the  haematuria,  in  some  cases  there  can  be  no  doubt 
that  there  is  a  direct  spread  of  the  infection  to  the  kidney,  as  in  a  case  reported 
by  Seelig,  in  which  a  perityphlitic  abscess  and  a  gangrenous  appendix  lay  on  the 
kidney. 

In  cases  in  which  the  appendix  is  adherent  to  the  ureter,  it  may  cause 
venous  congestion  and  consequent  bleeding  from  the  mucous  membrane  of  the 
ureter,  or  inflammation  and  swelling  of  the  mucous  membrane,  which  may  give 
rise  to  obstruction  of  the  ureter  and  so  predispose  to  acute  pyehtis  and  haema- 
turia, as  in  the  cases  recorded  by  Hunner. 

These  two  theories  will  not,  however,  account  for  cases  in  which  the  appendix 
is  not  in  contact  with  any  part  of  the  urinary  tract.  They  must  probably  be 
explained  either  on  the  ground  that  there  is  a  toxic  nephritis,  or  that  the  kidney 
is  the  site  of  emboli  or  thrombosis.  Von  Frisch  thinks  that  the  haematuria  is 
probably  due  to  embolism  or  thrombosis,  the  presence  of  blood-casts  supporting 
this  theory ;  he  suggests  that  a  retrograde  thrombosis  may  take  place,  owing 
to  the  free  communication  between  the  veins  of  the  capsule  of  the  kidney,  the 
veins  of  the  peritoneum,  the  lumbar,  and  the  retroperitoneal  veins. 

Although  the  theory  of  toxic  nephritis  will  not  hold  good  in  the  majority  of 
cases,  owing  to  the  rapid  recovery  of  the  patient  from  the  attacks,  and  the  way 
in  which  no  trace  of  albumin,  no  casts,  nor  renal  epithelium  are  to  be  found  in 
the  urine  subsequently,  still  it  may  occur  occasionally. 

The  prognosis  in  the  haematuria  which  is  usually  associated  with  appendicitis 
is  excellent,  as  these  cases  clear  up  as  soon  as  the  appendix  has  been  removed, 
leaving  no  trace,  so  far  as  we  know,  of  any  after-effects.  On  the  other  hand,  if 
the  haematuria  supervenes  whilst  the  patient  is  gravely  ill  from  an  acute  attack 
of  appendicitis,  particularly  if  it  is  comphcated  by  an  abscess  or  general  peri- 
tonitis, the  prognosis  is  more  serious. 

Bacteriology. — There  is  no  doubt  that  the  great  majority  of  cases  of  appendi- 
citis are  due  to  the  Bacillus  coli  communis  and  Streptococcus  pyogenes,  either 
separately  or  together.  In  most  cases  the  former  is  to  be  found  alone,  in  others 
the  Bacillus  coli  and  Streptococcus  in  pure  culture.  Other  organisms,  both 
aerobic  and  anaerobic,  are  sometimes  found,  but  they  usually  play  a  sub- 
sidiary part  and  only  represent  a  secondary  infection. 

The  prognosis  in  the  case  of  a  streptococcal  infection  is,  as  a  rule,  more 
serious  than  in  the  case  of  infection  by  the  Bacillus  coli.  Kelly  states  that  the 
Streptococcus  pyogenes  is  especially  associated  with  cases  of  very  severe  infection, 
and  is  the  usual  cause  of  extensive  and  rapidly  fatal  peritonitis.  This  fully  bears 
out  my  own  experience,  and  I  have  frequently  found  it  present  in  cases  of  severe 
infection,  with  gangrene  of  the  appendix  and  possibly  extension  to  the  caecum. 
Those  cases  in  which  the  temperature  remains  raised  for  a  week  or  ten  days  after 


APPENDICITIS  67 


removal  of  the  appendix,  in  spite  of  apparently  satisfactory  drainage,  are  not 
uncommonly  due  to  streptococcal  septicaemia.  If  the  abdomen  is  explored,  but 
little  pus  will  be  found,  and  what  there  is  is  present  in  small  loculi.  If  the 
adhesions  are  broken  down  to  let  out  these  smaU  collections  of  pus,  there  is  a 
great  danger  of  faecal  fistula. 

Pregnancy. — -There  has  been  a  good  deal  of  discussion  on  the  relation  between 
pregnancy  and  appendicitis,  and  the  influence  of  the  one  upon  the  other  ;  but  the 
number  of  cases  that  have  been  reported  is  comparatively  small,  and  it  is  there- 
fore difficult  to  draw  any  satisfactory  conclusions.  In  the  present  series  there 
were  only  2  patients  who  were  pregnant,  one  three  months  and  the  other  six 
months  ;  in  one  the  appendix  was  inflamed,  without  the  formation  of  pus  or 
peritonitis.  The  wound  healed  by  first  intention,  and  the  patient  made  an 
excellent  recovery.  In  the  other  case  the  illness  was  of  longer  duration,  and 
there  was  local  peritonitis  at  the  time  of  operation ;  but  the  patient  recovered, 
pregnancy  being  undisturbed. 

If  a  patient,  who  has  recently  recovered  from  an  attack  of  appendicitis, 
becomes  pregnant,  is  she  likely  to  have  a  recurrence  of  the  appendicitis  during 
her  pregnancy  ?  Apart  from  the  ordinary  probabilities  of  a  recurrence  of  an 
attack  of  appendicitis  independently  of  pregnancy,  we  have  to  take  into 
consideration  the  altered  intra-abdominal  conditions.  These  have  given  rise 
to  a  good  deal  of  speculation  on  the  part  of  various  authors,  with  the  result  that 
exactly  opposite  opinions  have  been  held.  On  the  one  hand,  we  can  say  that 
the  constipation  which  is  so  frequently  present  in  pregnancy  is  a  predisposing 
factor,  and  would  favour  an  attack  of  appendicitis.  On  the  other  hand,  the 
connective  tissue  in  the  lower  abdomen  becomes  looser  and  all  the  parts  more 
vascular,  which  would  not  favour  such  an  attack.  But  when  we  take  into 
consideration  the  actual  facts,  we  see  that  the  number  of  women  who  suffer  from 
appendicitis  during  pregnancy  is  extremely  small.  For  example,  among  the 
1000  cases  of  appendicitis  which  I  collected  in  1905,  there  were  309  females, 
and  6  of  them  were  pregnant,  a  proportion  of,  roughly,  2  per  cent.  In  the 
present  series  there  were  394  females,  2  being  pregnant,  a  percentage  of 
about  0-5  per  cent.  This  proportion  is  somewhat  larger  than  that  which 
obtains  in  the  statistics  of  Sonnenburg  and  Krogius,  quoted  by  Renvall. 
Sonnenburg,  among  2000  cases  of  operation  for  appendicitis  on  both  sexes,  had 
4  cases  of  pregnancy,  and  Krogius,  in  900  cases,  had  i  of  pregnancy.  Renvall 
also  quotes  Fraenkel,  who,  out  of  40,000  gynaecological  and  obstetric  cases, 
had  only  4  cases  of  appendicitis  associated  with  pregnancy,  and  Schauta,  who 
had  4  cases  out  of  30,000. 

Now  although  it  is  obvious  that  when  the  total  period  of  the  pregnancies  of 
any  one  woman  is  taken,  it  forms  only  a  very  small  part  of  her  life,  the  number 
of  pregnant  patients  in  the  above  statistics  is  so  exceedingly  small  that  it  suggests 
that  pregnancy  does  not  have  any  particular  influence  in  predisposing  to  an 
attack  of  appendicitis.  Further,  Renvall  found  that  attacks  of  appendicitis, 
whether  primary  or  secondary,  depend  but  little,  or  not  at  all,  on  the  month  of 
pregnancy,  because  the  number  of  cases  which  occurred  in  the  second  and  third 
months,  when  the  uterus  can  exert  no  pressure  and  no  traction  on  the  appendix , 
was  proportionately  equal  to  those  which  occurred  in  the  later  months  of 
pregnancy.  We  may  therefore  consider  that  the  influence  of  pregnancy  on  the 
incidence  of  appendicitis  is  not  proved. 

We  next  pass  on  to  consider  the  probable  course  of  events  in  a  patient 
who  has  an  attack  of  appendicitis  during  her  pregnancy.  First  of  all,  one  can 
say  without  hesitation  that  if  operation  is  performed  in  the  early  stage,  that  is, 
within  the  first  twenty-four  hours,  the  prognosis  difiers  very  little  from  that  in 


68  INDEX     OF     PROGNOSIS 

a  patient  who  is  not  pregnant,  and  the  same  holds  good  for  a  certain  number 
of  cases  of  abscess,  namely  those  which  do  not  come  into  contact  with  the  uterus. 
If,  however,  the  uterus  forms  part  of  the  wall  of  an  appendix  abscess,  the  prog- 
nosis becomes  more  serious.  The  great  danger,  of  course,  is  the  possibility 
of  miscarriage  or  labour  ;  for  the  rapid  diminution  in  the  size  of  the  uterus  will 
break  down  the  adhesions  and  flood  the  peritoneal  cavity  with  the  pus  which 
escapes  from  the  abscess.  Several  cases  have  been  reported  in  which  the  patient 
died  from  general  peritonitis,  the  result  of  a  ruptured  appendix  abscess,  two  or 
three  days  after  labour. 

With  regard  to  the  effect  on  the  pregnancy,  a  simple  appendicitis  does  not 
necessarily  predispose  to  abortion  or  labour.  On  the  other  hand,  if  an  abscess 
has  formed,  the  prospects  are  not  so  good,  for  if  it  lies  in  contact  with  the  uterus 
there  is  a  considerable  probability  that  it  will  bring  about  miscarriage  or  labour, 
a  probability  which  becomes  a  certainty  if  there  is  general  peritonitis.  At  the 
same  time  it  must  be  remembered  that  abscesses  have  been  evacuated  without 
disturbing  the  pregnancy. 

Lastly,  with  regard  to  the  child  ;  in  nearly  all  cases  in  which  appendicitis 
puts  an  end  to  the  pregnancy,  the  child  is  born  dead,  or  dies  within  a  few 
hours  of  its  birth.  An  interesting  case  has  been  reported  by  Pinar,  in  which 
the  B.  coli  communis  was  found  in  pure  culture  in  the  vessels  of  the  umbilical 
cord.  Kronig  also  reported  a  case  in  which  the  B.  coli  communis  was  found  in 
pure  culture  in  the  organs  of  the  foetus,  in  the  placenta,  and  in  the  large  uterine 
veins. 

What  then  is  the  best  line  of  treatment  to  adopt  in  a  patient  who  becomes 
pregnant  shortly  after  an  attack  of  appendicitis  ?  If  the  attack  was  a  severe 
one,  I  think  that  she  should  be  advised  to  have  the  appendix  removed  as  soon 
as  possible,  for  appendicectomy  in  the  quiescent  stage  is  attended  with  very  little 
risk  to  the  patient  and  is  not  likely  to  disturb  the  pregnancy.  In  this  way,  the 
danger  of  a  recurrent  attack  during  her  pregnancy  will  be  avoided,  an  attack 
which  might  be  accompanied  by  abscess  or  general  peritonitis,  and  which  would 
possibly  prove  fatal  to  both  mother  and  child.  If,  however,  the  attack  was  a 
very  mild  one,  and  therefore  a  recurrence  less  likely,  and  if  the  patient  would  be 
within  reach  of  surgical  aid  during  the  whole  of  her  pregnancy,  then  one  might 
wait  for  a  further  attack  to  develop,  on  condition  that  operation  should  be 
performed  as  soon  as  the  diagnosis  has  been  made. 

When  to  Operate. — ^We  now  have  sufficient  data  to  discuss  the  vexed  question, 
when  to  operate  in  appendicitis.  There  is  a  steadily  growing  consensus  of 
opinion  that  operation  should  be  performed  in  all  cases  of  appendicitis  as  soon 
as  the  condition  is  diagnosed.  For  at  the  beginning  of  an  attack  it  is  frequently 
extremely  difficult,  and  generally  impossible,  to  give  a  prognosis  and  to  say 
whether  the  patient  will  get  well  without  operation  or  not.  From  time  to  time 
various  methods  and  tests  have  been  announced  which  it  was  hoped  would 
indicate  the  necessity  for  operation  or  not ;  but  none  of  them  have  been  found 
to  be  absolutely  reliable.  First  there  was  the  qiiestion  of  leucocytosis.  Then 
there  was  the  test  administration  of  castor  oil;  if  the  patient  was  not  worse 
after  the  castor  oil,  operation  was  not  performed  ;  if  he  was,  operation  was 
considered  to  be  indicated— a  very  dangerous  method,  one  which  should  never 
be  used  in  private  practice,  and  extremely  rarely  in  hospital.  Oehlecker  drew 
attention  to  the  fact  that  the  viscosity  of  the  blood  increases  in  proportion  to 
the  severity  of  the  attack,  and  shows  in  an  especial  degree  how  widely  the 
peritoneal  cavity  is  involved.  The  more  extended  the  peritonitis,  the  higher 
the  viscosity  ;  but  it  does  not  tell  how  far  the  appendix  itself  is  diseased  ;  for 
example,  an  appendix  may  be  gangrenous,  but  if  it  lies  on  the  outer  side  of  the 


APPENDICITIS  69 


caecum  and  there  is  little  or  no  peritonitis,  the  blood   may  only  show  a  very 
slightly  increased  viscosity. 

Then  again,  at  one  time  it  was  said,  "  If  the  patient  is  not  improving  at  the 
end  of  forty-eight  hours,  operate."  My  reply  to  this  is,  of  course,  that  one  should 
not  wait  until  the  end  of  the  first  forty-eight  hours  ;  but  if  the  diagnosis  has  been 
made,  operation  should  be  performed  at  once.  To  emphasize  this,  we  need  only 
point  to  the  figures  given  above,  which  show  that  the  mortality  in  patients 
operated  upon  during  the  first  twenty -four  hours  is  1-2  per  cent,  during  the 
second  twenty-four  hours  3-9  per  cent,  and  during  the  third  twenty-four  hours 
8-7  per  cent. 

It  may  be  objected  that  it  is  not  necessary  to  operate  upon  all  cases  of 
appendicitis,  and  that  many  of  them  will  subside  without  any  operative  inter- 
ference whatever.  This  is  perfectly  true.  The  crucial  point,  however,  is  that, 
in  most  cases,  we  cannot  tell  at  the  beginning  of  an  attack  whether  it  is  going 
to  be  a  catarrhal  one,  or  whether  gangrene  will  set  in.  Any  surgeon  who  has 
a  fairly  wide  experience  of  operating  on  these  cases  can  readily  call  to  mind 
patients  who  presented  symptoms  and  signs  of  a  comparatively  mild  attack  of 
appendicitis,  but  in  whom  a  gangrenous  appendix  was  found  at  operation. 
Kiimmell,  in  discussing  the  importance  of  early  operation,  mentions  that  out  of 
237  cases  upon  which  he  operated  during  the  first  forty-eight  hours  of  the  attack, 
115,  nearly  50  per  cent,  showed  a  gangrenous  or  perforated  appendix. 

Then  again,  apart  from  the  very  small  mortality  of  operations  performed 
during  the  first  twenty-four  hours,  a  point  of  great  importance  is  this,  that  by 
operating  early  and  removing  the  diseased  focus,  the  chances  of  complications 
supervening  are  greatly  diminished.  This  is  particularly  the  case  with  such 
complications  as  ileus  and  the  other  forms  of  intestinal  obstruction,  thrombosis 
of  the  femoral  veins,  pylephlebitis,  and  so  on.  For  example,  if  we  compare  my 
T905  series  of  cases  with  the  present  series,  we  find  that  the  number  of  cases  of 
faecal  fistula  has  been  reduced  from  49  to  25,  and  of  thrombosis  of  the  femoral 
vein  from  12  to  4.  There  were  only  17  cases  of  pulmonary  complications  as 
opposed  to  45  in  1905,  and  2  cases  of  pylephlebitis  as  opposed  to  4.  Further, 
with  very  few  exceptions,  all  the  complications  in  the  present  series  occurred 
in  patients  who,  at  the  time  of  operation,  were  suffering  from  either  abscess  or 
general  peritonitis. 

Another  point  in  favour  of  early  operation,  apart  from  the  prevention  of  such 
grave  conditions  as  the  formation  of  an  abscess  or  general  peritonitis,  is  the  fact 
that,  in  the  great  majority  of  cases,  it  is  possible  to  close  the  wound  and  obtain 
union  by  first  intention.  Where  an  abscess  or  general  peritonitis  is  already 
present,  this  is  not  possible,  and  we  have  to  face  the  possible  development  of  a. 
ventral  hernia,  apart  from  the  prolonged  stay  in  bed  which  ^  is  necessitated  by 
these  conditions. 

Lastly,  another  point  of  considerable  importance  in  the  prognosis  is  the  fact 
that  appendicitis  is  essentially  a  disease  where  relapse  is  the  rule,  and  freedom 
from  recurrence  is  the  exception.  The  only  cure  is  operation  :  medical  treat- 
ment may  be  successful  in  tiding  the  patient  over  an  attack,  but  the  probability 
that  further  attacks  will  supervene  is  very  great.  Of  233  cases  collected  b}' 
Karrenstein,  50-2  per  cent  had  further  attacks,  60  per  cent  in  the  first  year,  20 
per  cent  in  the  second,  and  20  per  cent  subsequently.  Of  1933  cases,  Kiimmell 
found  that  989,  or  51-1  per  cent,  had  had  previous  attacks. 

When  operation  is  performed  in  the  early  stages,  the  appendix  can  always  be 
removed,  and  thus  the  possibility  of  further  attacks  be  obviated. 

Recurrence. — The  question  of  recurrence  must  be  considered  from  three  stand- 
points :    First,  the  probabiUty  of  recurrence  in  a  patient  who  has  an  attack  of 


70 


INDEX     OF     PROGNOSIS 


appendicitis,  mild  or  acute,  without  abscess  formation ;  second,  the  recurrence 
of  symptoms  after  appendicectomy ;  and  third,  recurrence  after  an  abscess 
when  the  appendix  has  not  been  removed.  Statistics  which  are  compiled  at 
the  present  day  have  not  the  same  value  as  those  of  five  or  six  years  ago, 
owing  to  the  greater  frequency  of  operative  interference.  For  nowadays,  not 
only  is  it  the  rule  for  a  patient  who  has  an  attack  of  appendicitis  to  be  operated 
upon,  either  immediately  or  at  the  conclusion  of  the  attack ;  but  also  many- 
cases  of  chronic  appendicitis,  where  there  has  never  been  an  acute  attack,  are 
recognized  and  treated  by  operation. 

The  great  tendency  to  recurrence  is  pointed  out  by  Hoffmann,  who  found  that 
of  2331  cases  operated  upon  for  appendicitis,  no  less  than  1202,  that  is  51-1  per 
cent,  had  had  previous  attacks,  and  this,  he  says,  was  the  minimum,  for  in  a  large 
number  of  cases  there  was  no  mention  as  to  whether  the  patient  had  had  a 
previous  attack  or  not. 

I  have  already  referred  to  Karrenstein's  conclusions  :  we  there  see,  that 
of  patients  who  are  going  to  have  recurrent  attacks  of  appendicitis,  80  per  cent 
will  have  them  within  two  years.  But  at  the  same  time  it  must  be  borne  in 
mind  that  attacks  maj^  recur  after  as  many  as  eighteen,  twenty,  or  even  twent}-- 
two  years  have  elapsed. 

It  seems  possible  that  as  the  attacks  are  repeated  they  become  less  severe. 
In  1905  I  found  that  of  299  patients  who  had  an  appendix  abscess,  1S7  had  had 
no  previous  attacks.  This  is  still  more  striking  in  the  case  of  general  peritonitis. 
Of  35  cases  in  which  allusion  was  made  to  the  presence  or  absence  of  previous 
attacks,  in  no  less  than  31  the  patients  had  not  had  appendicitis.  Three 
patients  had  had  one  attack,  and  i  patient  had  had  two  attacks.  That  is  to 
say,  in  88-6  per  cent  it  was  the  first  attack. 

Table  D. — Cases  of  Abscess   and   General  Peritonitis  admitted   to  the 

London  Hospital  from  July  ist,  1900,  to  August  15TH,  1904,  and 

their    Relation    to    Previous    Attacks    of    Appendicitis. 


Nnmber  ol 
Cases 

Number  of  Previous  Attacks 

of  Appendicitis 

Not  Stated 

None 

One 

Two 

Three  or 
more 

Abscess       .         -         -         . 
General  peritonitis 

499 
101 

200 

66 

187 
31 

67 
3 

19 
1 

^0 

Total 

600 

266 

218 

70 

■ 
20 

26 

These  figures  are,  of  course,  small,  and  deductions  from  them  must  be  made 
with  some  reserve  ;  but  it  is  reasonable  to  assume  that  the  adhesions  which 
result  from  the  first  attack  tend  to  limit  the  inflammation  in  subsequent  ones 
to  the  immediate  neighbourhood  of  the  appendix. 

Whether  a  patient  who  has  just  recovered  from  an  attack  of  appendicitis  should 
have  his  appendix  removed  or  not,  depends  upon  the  severity  of  the  attack. 
If  it  was  a  very  mild  one,  of  brief  duration,  with  little  pyrexia  or  general 
disturbance,  there  is  a  considerable  probability  that  the  appeiidix  will  recover 
completely  and  bear  no  trace  of  the  inflammation.  Under  these  circumstances 
there  is  no  reason  to  anticipate  a  recurrence,  and  therefore  operation  is  not 
necessary  unless   a   further   attack  develops.     If,  however,  the   patient   has  a 


APPENDICITIS  71 


recurrence,  the  appendix  should  be  removed  whether  the  attack  be  a  slight 
one  or  not. 

If  it  was  a  severe  one,  changes  will  probably  take  place  in  the  appendix, 
resulting  in  a  stricture,  kinking,  adhesions,  etc.,  which  predispose  to  a  recur- 
rence, and  therefore  operation  should  be  advised. 

An  exception  may  perhaps  be  made  where  the  patient  has  had  numerous  fairly 
acute  attacks  of  appendicitis,  perhaps  six  or  seven,  and  each  has  been  less  severe 
than  the  preceding  one.  If  these  cases  are  operated  upon,  it  is  usual  to  find 
the  appendix  partially  destroyed,  great  fibrous  thickening  of  the  submucous 
coat,  and  the  lumen  almost  or  entirely  obliterated  for  a  great  part  of  its  extent. 
Adhesions  are  commonly  met  with  which  shut  off  the  appendix  more  or  less 
completely  from  the  surrounding  peritoneal  cavity.  A  patient  with  an  appendix 
in  this  condition  is  unlikely  to  have  a  very  serious  attack,  and  therefore,  if 
strongly  opposed  to  operation,  he  may  be  treated  on  medical  lines.  At  the  same 
time  one  must  bear  in  mind  the  pathological  conditions  in  the  upper  abdomen 
which  are  frequently  associated  with,  and  apparently  caused  by,  chronic  inflam- 
mation of  the  appendix.  If  there  are  symptoms  of  dyspepsia  the  appendix 
should  certainly  be  removed  lest  worse  befall. 

Recurrence  of  Symptoms  after  Appendicectomy. — Sir  Frederick  Treves  went 
fully  into  this  question  in  1905,  and  made  a  valuable  contribution  to  the  subject 
by  analyzing  the  cases  of  45  patients  who  consulted  him  because  they  were  no 
better  for  the  operation,  or  still  had  '  attacks  '  which  had  been  unaffected  by  the 
removal  of  the  appendix.  In  the  following  table  he  gave  a  list  of  the  patients 
who  consulted  him,  and  the  varying  conditions  which  gave  rise  to  their  symptoms. 

Table  E. — Patients    who    Complained    of    Imperfect   Relief    after    the 
Removal    of   the   Appendix  in    the    Quiescent   Period. 

Appendix  imperfectly  removed         ...  -  -  2 

Ovarian  trouble  coexisting    ------  9 

Persisting  or  relapsing  colitis  ...  -  -  8 

Persisting  local  pain  ....--  7 

Neurasthenia  or  hypochondriasis      -----  5 

Continued  attacks  due  to  gall-stones  -  -  -  -  3 

„  ,,         colic        -  -  -  -  -  2 

„  ,,         movable  kidney  -  -  -  2 

,,  ,,         stone  in  kidney  -  -  -  i 

,,  ,,  an  unexplained  cause    -  -  -  i 

Tender  mass  in  the  right  iliac  fossa  -  -  -  '  5 

45 

Reference  to  tliis  table  shows  that  in  a  large  proportion  of  the  cases,  the 
symptoms  were  not  caused  by  appendicitis,  but  by  various  other  conditions 
such  as  gall-stones,  colitis,  etc.,  and  consequently  the  failure  of  the  operation 
was  due  to  an  incorrect  diagnosis. 

In  2  cases  the  whole  of  the  appendix  had  not  been  removed,  and  the  patient 
had  further  attacks  in  the  stump  which  was  left. 

In  5  cases  the  symptoms  were  ascribed  to  neurasthenia  and  hypochondriasis. 

In  5  other  cases  a  tender  swelling  appeared  in  the  right  iliac  fossa  some  time 
after  the  operation.  In  3  of  them  the  tender  swelling  was  a  faBcal  mass ;  in 
I  it  was  inflammatory,  and  disappeared  in  a  few  weeks  ;  in  the  remaining  case 
it  was  due  to  tuberculous  glands. 

At  the  request  of  Sir  Frederick  Treves  I  wrote  to  363  London  Hospital  patients 
who  had  had  the  appendix  removed  in  the  quiescent  stage.  Among  other 
questions,  I  asked  if  they  had  had  any  further  attacks,  resembling  those  which 


72  INDEX     OF     PROGNOSIS 

they  had  had  before  the  operation.  There  were  242  repUes:  231  said  that 
they  had  been  quite  free  from  pain;  11,  a  proportion  of  4-5  per  cent,  said  that 
they  had  had  further  attacks. 

Among  the  patients  who  had  the  appendix  removed  during  an  operation  for 
general  peritonitis  or  abscess,  the  percentage  was  rather  higher,  as  out  of  107 
patients  who  rephed,  6,  or  5-6  per  cent,  complained. 

It  is  not  surprising  to  find  a  higher  percentage  of  imperfect  reUef  in  the 
latter  circumstances,  on  account  of  the  gross  intraperitoneal  disturbance,  and 
also  because  of  the  increased  difficulty  of  removing  the  appendix  in  the  case 
of  an  abscess,  especially  if  there  have  been  previous  attacks. 

In  2  of  the  patients  to  whom  I  wrote,  a  second  operation  was  necessary  to 
remove  the  remains  of  an  appendix  which  had  been  incompletely  removed  at 
the  first  operation  ;  in  one  of  them,  removal  of  the  appendix  was  originally 
attempted  during  a  quiescent  period,  in  the  other,  during  an  operation  for  abscess. 

While  giving  adequate  weight  to  the  above  investigations,  it  is  important  to 
remember  that  they  were  made  nine  years  ago,  and  that  since  then  we  have  made 
enormous  strides  in  our  knowledge  of  appendicitis,  and  in  its  diagnosis  and 
treatment.*  We  may  therefore  reasonably  suppose  that  a  considerable  propor- 
tion of  the  causes  which  were  responsible  for  the  lack  of  success  of  the  operation, 
as  illustrated  by  the  table  drawn  up  by  Sir  Frederick  Treves,  are  no  longer 
operative.  Consequently,  with  proper  care  in  the  selection  of  cases,  added  to 
modern  technique,  the  operation  undertaken  in  the  quiescent  stage  should  be 
completely  successful,  and  afiord  entire  rehef  in  probably  not  less  than  97  per 
cent  of  them. 

Recurrence  after  an  Abscess. — I  now  turn  to  those  cases  of  appendix  abscess 
in  which  the  pus  is  evacuated  but  the  appendix  is  not  removed.  In  1905,  at  the 
discussion  before  the  Royal  Medico-Chirurgical  Society,  the  general  feehng  was 
that  if  a  patient  had  an  appendix  abscess,  his  chances  of  having  a  further  attack 
were  very  shght ;  and  it  was  even  said,  that  if  a  concretion  was  found  in  the  pus, 
there  would  be  no  further  attacks.  Credit  must  be  given  to  Battle  for  so 
vigorously  advocating  removal  of  the  appendix  in  all  cases  of  abscess  ;  if  it  could 
not  be  done  easily  at  the  time  the  abscess  was  drained,  he  advised  an  operation 
during  the  quiescent  stage. 

At  the  present  time  it  is  the  usual  practice,  when  operating  upon  an  abscess, 
to  remove  the  appendix  unless  there  is  great  difficulty  in  doing  so  ;  but  eight 
years  ago  it  was  the  rule  to  be  content  with  opening  the  abscess,  and  not  to 
remove  the  appendix  unless  it  actually  presented  itself  during  the  operation. 

From  the  statistics  which  were  brought  forward  at  the  above  meeting,  I  have 
been  able  to  collect  the  following  cases  in  which  an  abscess  formed  and  was 
evacuated  without  the  appendix  being  removed,  and  in  which  the  question  of 
further  attacks  was  investigated.  From  St.  George's  Hospital  there  were  15 
cases  ;  2  of  them  had  further  attacks,  after  which  the  appendix  was  removed. 
Pearce  Gould  brought  forward  71  cases:  41  occurred  in  his  hospital  and  30  in  his 
private  practice  ;  4  of  the  former  and  i  of  the  latter  had  suosequent  attacks 
of  appendicitis  for  which  the  appendix  was  removed.  Battle  operated  on 
54  cases  of  appendix  abscess  which  recovered,  and  no  less  than  12  had  further 
symptoms  necessitating  appendicectomy.  Together  this  gives  a  total  number 
of  140  cases,  19  of  which,  that  is  about  13-5  per  cent,  had  further  attacks. 

For  the  same  meeting,  I  wrote  to  and  had  replies  from  133  patients  who  had 
had  an  abscess  or  general  peritonitis  in  whom  the  appendix  had  not  been  removed  ; 
21  of  them  said  that  they  had  had  further  attacks,  a  proportion  of  14-6  per  cent. 

*  Lett,  "The  Present  Position  of  Appendicitis,"  Lancet,  1914,  Jan.  31,  p.  295. 


APPENDICITIS  73 


Taken  by  themselves,  these  replies  would  not  be  of  much  value,  unsupported  as 
they  are  by  medical  evidence,  but  the  result  coincides  so  closely  with  that 
obtained  in  the  above  140  patients,  13-5  per  cent  of  whom  had  so  much  trouble 
with  the  appendix  after  the  abscess  had  been  drained  that  a  further  operation 
was  necessary,  that  their  insertion  here  is  justified. 

Hoffmann  reported  that  out  of  78  cases  of  appendix  abscess,  44  had  trouble 
subsequently  in  the  form  of  abdominal  disturbance  or  pain,  and  that  in  a  certain 
proportion  there  were  further  definite  attacks  of  appendicitis. 

An  interesting  paper  was  published  by  Dodds  Parker  in  191 2.  He  recorded 
17  cases  of  appendicitis  with  abscess  formation  in  which  the  appendix  was 
removed  when  the  attack  had  subsided.  In  none  of  these  cases  was  the  appendix 
destroyed  or  its  lumen  obliterated,  but  in  all  of  them  there  were  adhesions,  kinks, 
and  scars,  which  of  course  predisposed  to  further  attacks. 

Sex. — It  has  long  been  recognized  that  the  male  sex  is  more  liable  to  attacks 
of  appendicitis  than  the  female,  and  numerous  statistics  have  been  published 
to  illustrate  the  incidence  of  appendicitis  in  the  two  sexes.  In  the  1905  series  I 
found  that  of  the  1000  cases,  682  were  males  and  318  females,  the  males  forming 
68-2  per  cent  of  the  total.  Of  the  898  cases  which  were  operated  upon  in  the 
London  Hospital  in  1912,  515  were  males  and  383  females,  a  percentage  of  57-3. 
Added  together,  in  1898  cases  there  were  1197  males,  that  is,  tyi  per  cent.  This 
agrees  closely  with  the  results  obtained  by  MacCarty,  who  compiled  2586  cases 
reported  by  four  different  writers,  of  which  64-7  per  cent  were  males. 

In  order  to  obtain  still  larger  numbers,  I  collected  all  the  cases  admitted  to 
the  London  Hospital  during  the  years  1901-1912.  I  found  that  there  were  3652 
males  and  2426  females,  a  total  of  6078.  This  means  that  the  male  patients 
formed  almost  exactly  60  per  cent  of  the  cases,  and  coincides  remarkably  with 
Kelly's  investigations,  for  he  found  that  in  the  Johns  Hopkins  Hospital  the 
proportion  of  men  to  women  was  as  60  to  40. 

The  preponderance  of  the  male  sex  is  not  limited  to  adults  only  ;  the  same 
holds  good  in  the  case  of  children.  In  1912,  99  children  were  admitted  to  the 
London  Hospital  suffering  from  appendicitis  ;  61  were  boys  and  38  girls,  a  male 
percentage  of  61  •6. 

Why  the  male  sex  should  be  more  subject  to  appendicitis  than  the  female  is  not 
known,  though  numerous  explanations  have  been  offered,  ranging  from  an  alleged 
additional  blood-supply  in  the  female  sex  through  a  branch  of  the  ovarian  artery, 
to  greater  exposure  to  injury  and  the  excessive  use  of  tobacco  in  the  male  sex. 

As  to  the  severity  of  the  attack,  although  men  are  more  frequently  subject  to 
appendicitis,  the  attacks  appear  to  be  more  serious  in  the  female  sex,  and  are 
attended  by  a  higher  mortality  ;  for  example,  of  the  515  men,  14  died  ;  of  the 
383  women,  16  died,  giving  a  male  mortality  of  2-7  per  cent,  while  the  female 
mortality  was  4-2  per  cent.  This  suggests  that  although  the  male  sex  is  more 
frequently  affected,  roughly  in  the  proportion  of  6  to  4,  the  attacks  are  more 
serious  and  more  frequently  fatal  in  the  female  sex. 

Age. — The  age  at  which  appendicitis  occurs  varies  within  wide  limits, 
although,  as  we  shall  see  presently,  there  is  a  very  definite  period  of  life  when 
the  disease  is  especially  common.  In  the  present  series  the  youngest  patient 
was  10  months  old,  and  the  oldest  72  years  ;  both  recovered.  The  oldest  patient, 
however,  that  I  know  of,  was  a  gentleman  of  eighty-four,  upon  whom  I  operated 
and  from  whom  I  removed  a  gangrenous  appendix.  He  made  an  uninterrupted 
recovery.  On  referring  to  Table  F,  it  will  be  seen  that  of  the  1000  cases,  117 
occurred  in  children  up  to  the  age  of  ten,  339  between  eleven  and  twenty,  and 
275  between  twenty-one  and  thirty,  that  is,  614,  or  61-4  per  cent,  occurred 
between  the  ages  of  eleven  and  thirty,  and  731,  or  73-1  per  cent,  before  the  age 
of  thirty-one. 


74 


INDEX     OF     PROGNOSIS 


Table  F. — Mortality    of   Appendicitis   at   Different  Ages. 


Quiescent 

Inflamed 

Local 
Peritonitis 

Abscess 

General 
Peritonitis 

Total 

Mortal- 
ity 

Age 

R. 

D. 

R. 

D. 

R. 

D. 

R. 

D 

R. 

D. 

R. 

110 
330 
265 
159 
71 
33 

D. 

per  cent 

0—10 
11—20 

21—30 

31—40 

41—50 

Over  50 

12 

78 
103 
66 
28 
13 

0 
1 

0 

1 

0 
0 

40 
107 
76 
42 
14 
4 

0 
1 
0 
0 
0 
0 

13 

55 

27 

15 

5 

2 

3 
0 

2 
0 
0 
1 

33 

59 
51 
29 
21 
11 

0 
2 
4 
0 
1 
0 

12 
31 
'8 
7 
3 
3 

4 
5 
4 
0 

1 
2 

7 

9 

10 

1 
2 
3 

6 

2-7 
3-6 
0-6 

2-7 
8-3 

Total 

300 

2 

283 

1 

117 

6 

204 

7 

64       |16 

968 

32 

3-2 

R  =  liecovered.  1)  =  Died. 

As  regards  mortality :  it  has  long  been  said  that  the  mortality  is  especially 
great  in  the  earlier  and  later  periods  of  life,  and  it  is  interesting  to  see  that  the 
results  obtained  in  the  present  series  bear  this  out.  Among  117  cases  under 
eleven  years  of  age  there  vi^ere  7  deaths,  a  mortality  of  6  per  cent.  Between 
eleven  and  twenty  there  were  339  cases,  with  9  deaths,  a  mortality  of  2-7  per  cent, 
and  between  twenty-one  and  thirty,  275  with  10  deaths,  a  mortality  of  3-6  per 
cent.  We  next  come  to  the  period  between  thirty  and  fifty  ;  here  the  results 
are  very  remarkable,  as  in  233  cases  there  were  only  3  deaths,  giving  the  low 
mortality  of  1-3  per  cent.  It  is  always  dangerous  to  draw  conclusions  from 
statistics  unless  the  figures  are  very  large  and  all  causes  of  error  have  been 
excluded  as  far  as  possible  ;  still,  one  cannot  help  feeling  it  is  very  suggestive 
that  out  of  233  cases  there  should  only  be  a  mortality  of  1-3  per  cent. 

Over  the  age  of  fifty,  the  numbers  are  so  small  as  to  be  of  little  value.  There 
were  36  patients,  3  of  whom  died,  giving  a  mortality  of  8-3  per  cent.  One  is  not 
surprised  to  find  that  the  mortality  in  people  of  advanced  years  is  greater  than  that 
in  young  people  and  those  in  the  prime  of  life.  It  only  stands  to  reason  that  a 
patient  who  is  getting  on  in  years,  and  is  possibly  troubled  with  some  deficiency 
in  the  pulmonary,  cardiac,  or  renal  organs,  should  be  more  likely  to  fail  to  respond 
to  treatment,  and  should  succumb  from  heart  failure  or  pulmonary  complications. 


CHRONIC     APPENDICITIS. 

Chronic  Appendicitis  and  Conditions  associated  with  it.— So  far  I  have 
dealt  only  with  the  prognosis  in  acute  cases.  Chronic  appendicitis  must  also 
be  considered,  not  only  in  relation  to  the  possibility  of  further  acute  attacks,  but 
also  in  relation  to  other  more  remote  effects.  The  so-called  appendix  dyspepsia 
is  now  a  well-recognized  clinical  entity,  and  of  late  the  medical  profession  has 
realized  the  frequency  with  which  chronic  inflammation  of  the  appendix  is 
associated  with  important  pathological  conditions  in  the  upper  abdomen. 

Appendix  Dyspepsia. — It  is  now  generally  recognized  that  chronic  inflammation 
of  the  appendix  may  give  rise  to  symptoms  simulating  ulcer  of  the  stomach  or 
duodenum,  or  gall-stones ;  and  a  definite  diagnosis  between  these  various 
conditions  can  be  made  in  the  great  majority  of  the  patients,  if  the  case  is 
properly  investigated,  and  a  full  account  of  the  symptoms  obtained  and  thought- 
fully considered.  The  writings  of  Paterson  and  Moynihan  should  be  consulted, 
particularly  the  article  by  Moynihan  in  the  British  Medical  Journal,  January 
29th,    1910,   and  the   article  on   "  Appendix   Gastralgia  "   in  Paterson's  book. 


APPENDICITIS,     CHRONIC  75 


The  Surgery  of  the  Stomach.  I  may,  however,  touch  briefly  on  the  principal 
features  of  this  condition.  The  most  frequent  symptom  is  pain  or  discomfort 
in  the  epigastrium,  coming  on  at  a  varying  time  after  food,  sometimes  immedi- 
ately, in  other  cases  not  until  two  hours  or  more  have  elapsed.  It  is  frequently 
associated  with  distention  and  regurgitation.  Unlike  gall-stones,  the  character 
of  the  food  makes  little  difference.  An  important  point  of  differentiation 
between  the  dyspepsia  due  to  the  disease  of  the  appendix,  and  other  kinds, 
is  that  in  the  former  the  symptoms  are  practically  continuous  with  very  little 
variation,  whereas  in  the  latter  the  patients  nearly  always  have  intervals  of 
weeks,  or  even  months,  in  which  they  are  comparatively  free  from  pain. 
Occasionally,  but  in  my  experience  it  is  rather  exceptional,  the  pain  is  referred 
from  the  epigastrium  to  the  right  iliac  fossa  ;  tenderness  in  the  right  iliac  fossa 
is  occasionally  met  with,  but  may  be  entirely  absent.  Exercise  such  as  cycling, 
and  particularly  golf,  is  liable  to  bring  on  the  pain,  or,  if  present,  to  aggravate 
it.  Moynihan  has  drawn  attention  to  the  fact  that  pressure  on  the  appendix 
region  may  produce  epigastric  discomfort.  Conversely,  I  have  had  a  number 
of  patients  who  complained  of  pain  in  the  right  iliac  fossa  when  pressure  was 
made  upon  the  epigastrium.  A  somewhat  alarming  symptom,  which  is  by  no 
means  uncommon,  and  which  I  have  met  with  in  a  fair  proportion  of  my  cases, 
is  haematemesis. 

In  addition  to  the  fact  that  the  appendix  is  found  to  be  diseased,  the  proof 
that  these  symptoms  are  due  to  the  disease  of  the  appendix  lies  in  the  fact  that 
after  its  removal  all  the  symptoms  subside  and  the  patients  become  well. 

An  interesting  feature  in  these  cases  is  the  comparatively  small  number  of 
patients  who  have  had  previous  severe  attacks  of  appendicitis,  so  that  in  many 
cases  the  patient  has  no  reason  to  suppose  that  his  appendix  is  at  fault.  Harold 
Barclay  recently  drew  attention  to  this  in  an  article  in  the  American  Journal 
of  Surgery.     In  41  cases  he  found  only  5  with  a  direct  history  of  previous  attacks. 

Gastric  and  Duodenal  Ulcer. — It  would  appear  that  appendix  dyspepsia  is  a 
preliminary  stage  only,  and  that  if  it  is  neglected,  gastric  or  duodenal  ulcer  may 
supervene.  This  is  only  reasonable  when  v/e  consider  that  in  many  cases,  on 
opening  the  abdomen,  the  pyloric  portion  of  the  stomach  is  seen  to  be  in  a 
condition  of  spasm  (Moynihan)  ;  tlois  causes  delay  in  the  emptying  of  the 
stomach  and  so  predisposes  to  chronic  catarrh.  Then  again,  haematemesis  is 
generally  recognized  as  being  by  no  means  uncommon  in  appendix  dyspepsia, 
and  in  one  case  Paterson  observed  multiple  erosions  of  the  mucous  membrane 
of  the  stomach.  That  gastric  and  duodenal  ulcers  are  associated  with  chronic 
disease  of  the  appendix,  cannot  be  denied.  As  long  ago  as  1908  Mohnert  found 
that  in  64  per  cent  of  a  series  of  gastric  ulcer  cases  there  were  inflammatory 
changes  in  the  appendix.  Paterson  says  that  among  his  cases  of  duodenal 
ulcer  extending  over  a  period  of  three  years,  there  was  obvious  disease  of  the 
appendix  in  66  per  cent.  Moynihan,  taking  a  short  series  of  14  cases  of 
duodenal  ulcer,  examined  the  appendix  in  12,  and  in  80  per  cent  found  evidence 
of  long-standing  disease  in  it.  McCarty  and  McGrath  report  that  in  52  opera- 
tions for  gastric  and  duodenal  ulcer,  26-9  per  cent  of  the  appendices  which 
were  removed  were  partially  or  completely  obliterated.  In  my  own  experi- 
ence, it  is  the  exception  to  find  a  normal  appendix  in  the  presence  of  a  gastric 
or  duodenal  ulcer. 

Gall-stones. — These,  too,  apparently  come  into  relation  with  chronic  appen- 
dicitis. In  several  cases  where  the  symptoms  have  been  those  of  chronic 
cholecystitis  I  have  found  adhesions  round  the  gall-bladder  with  some  congestion 
of  its  mucous  membrane,  and  a  chronically  diseased  appendix.  Here  again, 
McCarty  and  McGrath  have  some  very  interesting  statistics.     In  57  autopsies 


76  INDEX     OF     PROGNOSIS 

on  cases  of  cholecystitis,  the  appendix  was  partially  or  completely  obliterated  in 
52  per  cent.  They  further  draw  attention  to  the  fact  that  of  365  cases  of  chole- 
cystectomy, in  23-2  per  cent  the  symptoms  began  at  or  under  25  years  of  age, 
a  period  when  appendicitis  is  extremely  common,  and  in  13  per  cent  there  was 
a  history  of  pain  and  soreness  in  the  appendix  region.  The  appendices  were  only 
removed  in  59  of  the  above  cases,  but  69  per  cent  of  these  appendices  showed 
undoubted  signs  of  disease.  They  suggest  that  the  sequence  of  events  is,  first, 
a  chronic  appendicitis  ;   secondly,  cholecystitis  ;   and,  finally,  gall-stones. 

It  is  now  generally  recognized  that  the  appendix  may  play  an  im.portant  part 
in  diseases  of  the  upper  abdomen,  and  that  no  operation  for  gastric  or  duodenal 
ulcer,  cholecystitis,  gall-stones,  and  possibly  pancreatitis,  is  complete  without 
examination  of  the  appendix,  and  its  removal  if  diseased. 

The  explanation  is  not  quite  clear,  though  there  are  numerous  theories.  Payr 
and  Mohnert  think  that  a  gastric  ulcer  may  be  caused  by  emboli  from  thrombosed 
veins  in  the  appendix  and  its  mesentery.  Another  explanation  is  that  these 
lesions  are  the  direct  result  of  intestinal  stasis,  caused  by  adhesions  and 
kinking  of  the  intestine,  the  infection  spreading  along  up  the  small  intestine 
to  the  stomach  and  duodenum.  This  may  be  so,  and  the  propounder  of  this 
theory.  Sir  Arbuthnot  Lane,  has  explained  the  disappearance  of  the  gastric 
or  duodenal  symptoms  after  appendicectomy  on  the  ground  that  the  removal 
of  the  appendix  relieves  the  obstruction  at  the  lower  end  of  the  ileum.  Lane, 
however,  considers  that  the  appendicitis  is  a  secondary  and  not  a  primary 
condition.  It  seems  to  me  that  the  explanation  may  lie  in  the  action  of  the 
ileo-colic  sphincter.  It  is  possible  than  an  appendix  which  is  in  a  state  of  chronic 
inflammation  may  so  interfere  with  the  ileo-caecal  reflex,  from  the  alteration  in 
the  character  of  its  secretion,  or  from  loss  of  contractile  power  in  consequence  of 
fibrosis  or  adhesions,  that  there  is  an  abnormal  delay  in  the  passage  of  faeces  from 
the  small  into  the  large  intestine.  MacEwen  had  the  opportunity  of  watching 
a  patient  who  lost  the  anterior  wall  of  his  caecum  through  an  explosion.  He 
observed  that  there  was  a  considerable  flow  of  alkaline,  glairy  mucus  from  the 
appendix  orifice  and  caecal  surface  shortly  after  food  was  introduced  into  the 
stomach,  and  that  it  was  greatly  increased  just  before  the  contents  of  the  ileum 
passed  through  the  ileo-caecal  valve  into  the  caecum.  Cannon  found,  in  his  experi- 
ments on  cats,  that  if  the  caecum  is  irritated  by  the  injection  of  croton  oil,  the 
passage  of  the  effluent  from  the  stomach  to  the  intestine,  and  from  the  small 
intestine  into  the  colon,  is  considerably  delayed.  In  further  support  of  this 
theory,  we  find  that  in  many  cases  of  appendix  dyspepsia  the  duodenum  is 
dilated. 

The  experiments  of  Bond  have  clearly  demonstrated  that  in  the  presence  of 
obstruction,  minute  foreign  bodies  can  be  carried  in  the  opposite  direction  to 
the  normal  flow  in  the  case  of  mucous  canals  and  gland  ducts,  and  one  may  con- 
clude that  in  intestinal  stasis,  micro-organisms  can  ascend  up  the  small  intestine 
to  the  duodenum  and  thence  to  the  stomach,  or  along  the  bile- ducts  to  the 
gall-bladder  or  to  the  pancreas. 

Whatever  the  value  of  these  theories  may  be,  the  fact  remains  that  a  patient 
who  is  suffering  from  chronic  inflammation  of  the  appendix  is  liable  to  have 
gastric  or  duodenal  ulcer,  or  gall-stones,  quite  apart  from  the  danger  of  a  further 
attack  of  appendicitis. 

The  prognosis,  therefore,  for  a  patient  who  has  had  one  attack  of  appendicitis 
is  somewhat  as  follows  :  Over  50  per  cent  of  patients  have  further  attacks, 
and  of  these,  60  per  cent  have  further  attacks  within  twelve  months,  and  80 
per  cent  within  two  years.  There  is  also  a  possibility  of  appendix  dyspepsia, 
gastric  or  duodenal  ulcer,  or  gall-stones  supervening.     It  is  not  possible  to  give 


ARSENIC    POISONING  77 


statistics  to  prove  the  frequency  with  which  the  latter  complications  arise. 
One  can  only  say,  in  accordance  with  the  statistics  already  referred  to,  that  in 
probably  75  per  cent  of  cases  of  gastric  and  duodenal  ulcer  the  appendix  is 
considerably  diseased,  and  that  in  175  cases  of  gall-stones  and  cholecystitis, 
McCarty  and  McGrath  found  the  lumen  of  the  appendix  obliterated  partially  or 
completely  in  nearly  50  per  cent,  and  consequently  we  may  assume  that  there 
was  evidence  of  disease,  less  pronounced,  in  considerably  more.  In  addition,  we 
have  to  remember  the  numerous  cases  of  appendix  dyspepsia  which  have  come 
to  operation  before  these  serious  complications  have  supervened. 

Colitis. — Lastly,  there  is  a  certain  number  of  cases  of  cohtis  which  are  the 
direct  result  of  chronic  inflammation  of  the  appendix.  It  may  be  taken  as  a 
general  rule  that  appendicectomy  is  indicated  provided  the  colitis  was  immedi- 
ately preceded  by  a  definite  attack  of  appendicitis  ;  under  these  circumstances 
the  prospect  of  a  cure  of  the  colitis  is  good.  This  favours  the  theory  that  the 
diseased  appendix  is  constantly  discharging  colonies  of  virulent  bacteria  into 
the  caecum  which  cause  and  keep  up  the  colitis.  If,  on  the  other  hand,  the 
coUtis  appeared  first  and  the  appendicitis  appears  to  be  secondary  to  it,  there  is 
little  prospect  of  curing  the  colitis  by  removing  the  appendix. 

References. — Aldehoff,  quoted  by  Hollander,  Berlin,  klin.  Woch.  1910,  i,  loii  ; 
Barclay,  Amer.  Jour.  Surg.  1912,  Aug.  ;  Battle,  Med.-Chir.  Trans.  1905,  Ix.xxviii, 
470;  Battle  and  Corner,  "The  Surgery  of  the  Diseases  of  the  Vermiform  Appendix," 
T910  ;  Bidwell,  Brit.  Med.  Jour.  1910,  ii,  507  ;  Bond,  Brit.  Med.  Jour.  1913, 
i,  645  ;  Brickner,  Amer.  Jour.  Surg.  1910,  xxiv,  208  ;  Carless,  Lancet,  1909, 
ii,  1540  ;  Corner,  Clin.  Jour.  1912,  May  29  ;  Cosens,  Lancet,  1909,  ii,  1469  ;  Denk, 
Beitr.  z.  klin.  Chirurg.  1913,  481  ;  Dieulafoy,  Sent.  Med.  1903,  xlii,  341 ;  Fairbank, 
Med.  Press  and  Circ.  1912,  i,  644  ;  Von  Frisch,  Wien.  klin.  Woch.,  1912,  xxv,  30  ; 
Garre  and  Quincke,  "The  Surgery  of  the  Lung,"  1912,  196;  Pearce  Gould,  Med.- 
Chirurg.  Trans.  1905.  Ixxxviii,  457  ;  Hamilton,  Brit.  Med.  Jour.  1912,  i,  950  ; 
Hammersley,  New  Zealand  Med.  Jour.  1909,  vii,  13 ;  Hoffmann,  Beitr.  z.  klin. 
Chirurg.  1912,  Ixxix,  305  ;  Hollander,  Berlin,  klin.  Woch.  1910,  i,  loii  ;  Hunner, 
Jour.  Amer.  Med.  Assoc.  1908,  April  25,  1328  ;  Karrenstein,  quoted  by  Kiimmell, 
Langenheck  Arch.  f.  klin.  Chirurg.,  1910,  xcii,  371;  Kelly  and  Hurdon,  "The 
Vermiform  Appendix  and  its  Diseases,"  1905  ;  Klemm,  Langenheck  Arch.  f.  klin. 
Chirurg.  xcv,  558  ;  Mittheil.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.  1906,  xvi,  580  ; 
Korte,  quoted  by  Hoffmann,  Beit.  z.  klin.  Chirurg.  1912,  Ixsix,  305  ;  Krogius,  Langen- 
heck Arch.  f.  Chirurg.  ,xcv,  759;  Kiimmell,  Langenheck  Arch.  f.  Chirurg.  1910,  xcii, 
371  ;  Lett,  Med. -Chirurg.  Trans.  1905,  Ixxxviii,  545  ;  McCarty  and  McGrath,  Ann.  of 
Surg.  1910,  lii,  801  ;  MacEwen,  Lancet,  1904,  ii,  995  ;  McWilliams,  Ann.  of  Surg.  1910, 
U,  909  ;  Mohnert,  Mittheil.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.  1908,  No.  r8,  469  ;  Moynihan, 
Brit.  Med.  Jour.  19 10,  i,  241  ;  Lancet,  1912,  i,  9  ;  Brit.  Med.  Jour.  1913,  ii,  171  ; 
Ney,  Johns  Hop.  Hosp.  Bull.  1912,  April,  123  ;  Oehlecker,  Berlin,  klin.  Woch.  1910,  i,  578  ; 
Parker,  Lancet,  1912,  i,  350  ;  Paterson,  Lancet,  1911,  i,  97  ;  Med.  Press  and  Circ. 
1912,  N.S.,  xciv,  63  ;  "  Surgery  of  the  Stomach,"  1913  ;  Payr,  Miinch.  med.  Woch. 
1905,  No.  17  ;  Verhandl.  d.  deutsch.  Gesellschaft  f.  Chir.  xxxvi,  636  ;  Douglas 
Powell,  Med. -Chirurg.  Trans.  1905,  Ixxxviii,  459  ;  Reichel,  quoted  by  Hollander,  Berlin, 
klin.  Woch.  1910,  i,  ion  ;  Reavall,  Eng.  Mittheil.  a.  d.  Gyncekol.  Klin.  1908,  vii,  18  ; 
Rheindorf,  Med.  klin.  Woch.  1913,  Jan.  12,  19,  and  26  ;  Rotter,  Langenheck  Arch  f. 
klin.  Chirurg.  1910,  xciii,  i  ;  Ruge,  Langenheck  Arch.  f.  klin.  Chirurg.  1911,  xciv,  711  ; 
Sasse,  Langenheck  Arch.  f.  Chirurg.  igii,  xciv,  549 ;  Seelig,  Ann.  of  Surg.  1908,  xlviii, 
388  ;  Sprengel,  Centr.  f.  Chirurg.  1911,  xxxviii,  33  ;  Still,  "  Common  Disorders  and 
Diseases  of  Childhood,"  1912,  268-279  ;  Telford,  Lancet,  1910,  ii,  1269  ;  Treves,  Med.- 
Ckirurg.  Trans.  1888,  165;  Med. -Chirurg.  Trans.  1905,  Ixxxviii.  431  ;  Widal,  Presse 
Med.  igi2,  Oct.  23,  872  :  Wilms,  Centr.  f.  Chirurg.  1909,  No.  48,  166  ;  Wilson, 
Brit.  Med.  Jour.  1912,  i,  829;  Woodforde,  Proc.  Roy.  Soc.  Med.  1910-1911,  Sect.  Stud. 
Dis.  Child.  81.  Hugh  Lett. 

ARSENIC  POISONING. — In  the  outlook  of  poisoning  by  arsenic,  much  depends 
on  whether  the  poisoning  is  acute  or  chronic.  In  the  former,  the  combination 
of  violent  purging  with  sanguineous  stools,  urgent  vomiting,  collapse,  cyanosis, 
suppression  of  urine,  convulsions,  and  coma,  form  a  chnical  grouping  from  which 
recovery  is  aU  but  hopeless. 


78  INDEX     OF     PROGNOSIS 

If  the  case  is  less  acute,  it  is  important  to  bear  in  mind  the  fact  that  remissions 
may  arise  in  the  symptoms,  leading  to  false  hopes,  and  that  such  patients  not 
infrequently  pass  into  a  fatal  relapse.  If  the  patient  recovers,  convalescence 
is  frequently  tedious,  and  later  on,  arsenical  nervous  phenomena  may  appear. 
The  chronic  form  of  poisoning  may  result  from  the  continuous  ingestion  of 
the  drug  over  long  periods,  or  may  follow  a  single  large  dose.  The  drug  may, 
however,  be  taken  in  large  quantities  over  very  prolonged  periods,  as  among 
the  natives  of  Styria,  without  harmful  effects  arising.  Signs  and  symptoms 
of  peripheral  neuritis  have  arisen  as  long  as  two  months  after  a  single  large 
dose.  Women  are  said  to  be  more  susceptible  to  nervous  phenomena  than 
men,  though  in  both  sexes  advancing  age  increases  the  liability  to  affection 
of  the  nervous  system. 

Children  tolerate  arsenic  well.  In  chronic  cases  in  which  keratosis  has 
appeared,  it  should  be  remembered  that  epithelial  cancer  sometimes  develops. 
Apart  from  this,  the  skin  lesions  generally  get  well  in  time  if  the  patient  is 
removed  from  any  further  intake,  although  in  some  cases  pigmentation  may 
remain  permanently.  /.  r.  Charles. 

ARTERIAL  TENSION,  HIGH. — It  is  convenient  to  give  some  httle  con- 
sideration to  this  subject  as  apart  from  that  of  arteriosclerosis,  but  most  of  the 
facts  relating  to  this  syndrome  will  be  found  under  the  latter  heading. 

The  pathological  facts  on  which  prognosis  should  be  based  are  :  (i)  Renal 
disease  is  the  cause  of  three-quarters  of  all  cases  of  high  tension  ;  (2)  The  tension 
cannot  rise  beyond  a  certain  point  without  wearing  out  the  circulatory  tube, 
either  at  the  cardiac  or  the  peripheral  end  ;  (3)  The  risks  are  therefore  those  of 
uraemia,  cardiac  failure,  and  cerebral  haemorrhage.  Janeway's  analysis  of 
too  fatal  cases  of  hypertension  (170  mm.  or  over)  showed  that  death  was  due 
more  or  less  directly  to  cardiac  failure  in  36,  to  uraemia  in  a  like  number,  and  to 
cerebral  haemorrhage  in  14.  In  de  Havilland  Hall's  20  cases,  on  the  other  hand, 
there  were  7  cardiac,  7  apoplectic,  and  only  3  uraemic  deaths. 

The  duration  of  life  in  Janeway's  cases  varied  from  four  months  to  eleven 
years,  and  averaged  a  little  less  than  four  years.  The  particular  kind  of  death 
did  not  have  much  bearing  on  the  duration  of  life. 

The  conditions  on  which  prognosis  is  founded  in  individual  cases  are  three  : 
(i)  The  height  of  the  pressure;  (2)  The  cause  or  causes;  and  (3)  The  general 
symptoms. 

I.  The  Height  of  the  Pressure. — The  following  facts  illustrate  the  first  point. 
Examination  of  a  large  series  of  insurance  figures  showed  that  the  mortality 
in  persons  with  a  systolic  pressure  exceeding  150  mm.  Hg  was  35  per  cent  in 
excess  of  the  average,  while  that  in  persons  whose  pressure  was  170  or  over  was 
no  less  than  four  times  as  heavy  as  that  of  the  average  man.  To  quote  de 
Havilland  Hall  again,  he  found  that  of  a  number  of  persons  followed  up  for  a 
definite  period,  the  mortality  rates  worked  out  as  follows  : — 

Mortality    According    to    Tension. 


Mortality 

Tension 

per  cent 

Below  120 

5-7 

120-140 

3-5 

141-160 

3-0 

161-180 

26-3 

181-200 

41-6 

Over    200 

53 

ARTERIAL     TENSION,    HIGH  79 


These  figures  suggest  that  pressures  up  to  160  in  middle-aged  people  do  not 
matter  much,  but  that  after  that  the  prognosis  grows  rapidly  worse  as  the  figure 
rises. 

In  assessing  the  importance  of  the  actual  systolic  pressure,  there  are  several 
modifying  circumstances  to  be  taken  into  consideration.  The  normal  rises  with 
advancing  years.  A  rough  and  ready  way  of  remembering  this  is  to  add  the 
patient's  years  to  100,  the  result  being  his  normal  pressure  ;  thus,  the  pressure 
at  the  age  of  forty  should  be  140  ;  this  gives  rather  high  results  for  the  later 
decades,  but  otherwise  it  will  serve.  Again,  sex  makes  a  difference  :  the  average 
tension  is  10  or  20  mm.  lower  in  a  woman  than  in  a  man  of  the  same  age.  In  a 
nervous  subject  there  is  always  a  risk  of  getting  too  high  a  reading,  and  some 
instruments,  such  as  the  Pachon  oscillometer,  give  artificially  high  results. 
We  have  not  here  entered  into  the  question  as  to  which  is  the  more  significant, 
rise  in  the  systolic  or  in  the  diastohc  pressure,  because  the  whole  matter  is  still 
unsettled,  and  for  the  present  it  is  better  to  limit  the  term.  '  high  tension  '  to 
cases  of  raised  systolic  pressure.  It  must  also  be  remembered  that  a  definitely 
rising  pressure  is  of  graver  import  than  a  stationary  one,  and  that  we  should 
particularly  fear  those  crises  of  hypertension  that  are  liable  to  arise  in  cases  of 
granular  kidney,  often  without  apparent  cause,  for  they  bring  into  the  case  a 
special  risk  of  cerebral  haemorrhage.  Conversely,  a  fall  in  tension  is  anything 
but  welcome  when  it  is  accompanied  by  threatenings  of  cardiac  breakdown. 

2.  The  Cause  or  Causes. — As  to  the  importance  of  causes,  it  must  never  be 
forgotten  that  in  the  great  majority  of  hyperpietics  the  kidneys  are  the  seat 
of  progressive  disease.  The  more  obvious  these  renal  lesions  are  to  the  clinician, 
the  worse  the  outlook.  If,  however,  there  are  contributory  causes  such  as 
excess  in  tobacco  or  food,  too  much  stress,  and  so  on — factors  that  are  in  some 
degree  susceptible  of  removal — the  prognosis  is  a  little  alleviated  ;  but  it  must 
be  confessed  that  even  when  everything  has  been  done  that  can  be  done,  the 
high  pressure  tends  still  to  persist  and  to  rise  relentlessly. 

3.  The  General  Symptoms. — There  is  no  need  to  go  fully  into  the  symptoms, 
since  the  calamities  that  are  to  be  anticipated— cardiac  failure,  uraemia,  and 
cerebral  haemorrhage — are  dealt  with  in  appropriate  articles.  The  only  point 
that  need  be  made  here  is  that  each  of  these  catastrophes  is  often  foreshadowed 
by  events  which  may  appear  trifling  in  themselves,  but  which  have  a  great 
significance  when  looked  at  as  foreshadowing  the  final  downfall.  The 
cardiac  symptoms  that  belong  to  this  category  are  those  that  indicate  failure 
of  contractility  ;  increasing  breathlessness,  periodic  dyspnoea,  swelling  about 
the  ankles,  precordial  pain  on  exertion,  and  the  bruit  de  galop.  The  likelihood 
of  an  apoplectic  seizure  is  also  often  hinted  at,  and  not  obscurely,  by  two  sets  of 
phenomena — haemorrhages  elsewhere  (nose,  retina)  and  cerebral  symptoms 
{headache,  vertigo,  mental  obfuscation,  transient  palsies,  and  so  on).  The 
transient  palsies  are  of  the  gravest  significance  :  temporary  aphasia,  hemianopia, 
strabismus,  hemiplegia,  and  such  like,  are  to  be  accepted  as  very  direct  fore- 
warnings  of  danger  in  persons  with  a  raised  blood-pressure.  Polyuria,  early 
morning  headache,  and  eye  symptoms  are,  according  to  Janeway,  precursors  of 
uraemia. 

The  effects  of  treatment  on  high  tension  are  disappointing.  In  favourable 
cases  dieting,  purgation,  and  systematic  moderate  exercise,  with  restriction  of 
mental  stress,  may  keep  the  pressure  from  rising  ;  but  once  high  pressures  of 
180  mm.  and  over  are  reached,  it  is  almost  impossible  to  get  them  down  again. 
Even  the  nitrites  are  often  ineffectual.  The  experiments  of  Matthew  and  others 
demonstrated  this  very  clearly.  They  further  proved  that  the  most  useful  of 
the  nitrites  for  continued  reduction  of   high  tension   was  erythrol  tetranitrate. 


8o  INDEX     OF     PROGNOSIS 

but  that,  owing  to  the  headache  which  this  is  apt  to  produce,  it  cannot  often  be 
used  continuously.  Under  these  circumstances  sodium  nitrite  in  frequently- 
repeated  doses  will  be  the  most  useful  vasodilator,  and  it  may  be  possible  to 
efiect  and  to  maintain  a  lowering  of  lo  or  20  mm.  The  fall  in  pressure  produced 
by  nitroglycerin  and  by  nitrite  of  amyl  is  too  fleeting  to  be  of  service  for  reduction 
of  a  persistently  high  pressure.  Potassium  iodide  cannot  be  relied  on  to  depress 
tension,  and  the  effect  of  venesection  is  also  very  brief.  Carey  F.  Coombs. 

ARTERIOSCLEROSIS. 

General  Outlook. — This  is  a  most  difficult  matter  to  write  about  in  a  case  of 
arteriosclerosis.  It  is  inevitable  that,  in  this  article,  there  should  be  some  over- 
lapping of  others,  that  dealing  wdth  high  blood-pressure  in  particular  ;  so  far 
as  may  be,  however,  my  purpose  is  to  indicate  what  is  to  be  feared  for  a  patient 
in  whom  the  arteries  are  found  to  be  sclerosed.  Now  the  practitioner's  attention 
is  directed  to  this  condition  under  tAvo  sets  of  circumstances.  First,  in  the 
course  of  a  general  examination — for  life  insurance,  for  example — it  is  found 
that  the  radial  arterj-  is  tortuous  and  hard,  beaded  it  may  be,  the  brachial  artery 
unduly  palpable,  the  abdominal  aorta  cord-like  and  throbbing  ;  in  a  word, 
general  arteriosclerosis  is  accidentally  discovered.  In  the  second  type  of  case, 
the  patient  complains  of  cerebral,  cardiac,  or  peripheral  symptoms,  and  the 
physical  examination  reveals  the  source  of  these  in  a  progressive  arterial  degener- 
ation. In  the  first  case,  the  disease  is  discovered  at  an  early  stage,  before  it  has 
begun  to  produce  tangible  interferences  with  function  ;  in  the  second,  these 
interferences  have  already  begun.  In  anj'  case,  chronic  arterial  disease  threatens 
life  and  health  in  one  way,  by  spoiUng  the  nourishment  of  various  organs  and 
tissues;  the  three  gross  manifestations ' of  this  process  are  cerebral  softening, 
cardiac  failure,  and  senile  gangrene.  There  is,  of  course,  the  risk  of  cerebral 
hsemorrhage  to  be  considered  ;  but  this  is  so  closely  connected  with  high  blood- 
pressure  that  it  will  only  receive  brief  comment  in  this  article. 

In  any  given  case,  there  are  three  things  to  consider  :  (i)  The  etiological 
factors  ;  (2)  The  stage  of  development  to  which  the  disease  has  attained  ;  and 
(3)  Its  distribution. 

I.  Etiological  Factors. — Confronted  by  arterial  degeneration  in  a  patient,  we 
naturally  want  to  know  the  reason  ;  and  two  aspects  of  this  question  present 
themselves  to  the  mind.  Sooner  or  later,  arterial  degeneration  is  the  common 
lot  of  man,  provided  he  Uves  long  enough  ;  in  other  words,  the  tunica  media  of 
the  arterial  tube  tends  '  normally  '  towards  decay  after  a  certain  age.  It  is 
said  (Adami)  that  this  downward  process  begins  at  about  thirt\'-five  ;  at  this 
time  the  katabohc  leanings  of  the  cells  of  the  arterial  media  begin  to  gain  the 
upper  hand.  Xow  the  rate  of  downward  progress  appears  to  depend  on  two 
sets  of  factors,  the  congenital  and  the  acquired.  Of  these  it  is  difficult  to  say 
which  is  cause  and  which  effect  :  the  writer  inclines  to  the  beUef  that  arterial 
degeneration  is  always  the  outcome  of  toxic  agencies  acting  on  a  tissue,  the 
tunica  media,  whose  \Tilnerabilit^'-  varies  ^Aith  certain  inherited  characteristics  at 
present  undefined.  Of  these  toxic  agencies,  some,  as  we  shall  see,  are  perfectly 
obvious,  others  less  so.  It  follows,  therefore,  that  in  estimating  the  prospects  of 
arterial  sclerosis  in  any  given  patient,  we  must  take  into  consideration :  first,  the 
kind  of  arteries  he  inherits  ;  second,  the  existence  or  non-existence  of  any 
toxaemias  to  which  his  arterial  decay  may  be  partly  ascribed. 

Congenital. — It  is  probable,  though  not  proved,  that  a  poorness  of  arterial 
make-up  is  inherent  in  certain  families  ;  that,  in  these,  the  medial  cell  is  particu- 
larly open  to  m.align  influences.  At  all  events,  there  are  families  whose  mem- 
bers seem  doomed  to  suffer  earl}'  arterial  degeneration  without  obvious  cause. 


ARTERIOSCLEROSIS  8i 


Assessment  of  the  familial  factor  is  conducted  along  obvious  lines  ;  the  age  at 
death  of  the  patient's  forebears,  their  fitness  for  work  during  the  decades  when 
men  commonly  begin  to  wear  out,  the  cause  of  death — all  have  to  be  passed 
under  review.  The  kind  of  history  to  make  a  man  repent  his  choice  of  ancestors 
is  that  in  which  generation  after  generation  has  decayed  mentally  at,  or  soon 
after,  sixty,  or  in  which  a  similar  liability  to  cardiac  breakdown  has  displayed 
itself.  The  family  doctor  often  enjoys  a  great  advantage  here  :  he  recollects 
how  the  father  of  the  patient  was  an  old  man  at  fifty-five,  and  assesses  the  pros- 
pects of  the  present  generation  accordingly.  The  first  definite  question  to  be 
answered  in  any  given  case,  then,  refers  to  the  quality  of  blood-vessel  which  the 
patient  inherits. 

Acquired. — The  acquired  factors  leading  to  arteriosclerosis  are  some  of  them 
obvious,  while  others  are  but  dimly  perceptible.  Among  the  obvious  ones  are 
certain  toxic  substances,  of  which  lead  is  the  most  conspicuous  example.  Some 
of  the  more  obscure  causes  hang  together  in  an  indefinite  kind  of  group  :  over- 
eating, excess  in  meat,  mental  or  muscular  stress,  high  arterial  tension,  renal 
disease. 

We  ought  to  consider  next,  then,  whether  any  such  cause  is  discernible  ;  if  so, 
whether  it  is  operative  at  the  time  of  examination  or  no  ;  and  whether,  if  operative, 
it  can  be  brought  to  an  end.  It  is  easy  enough  to  ask  these  questions,  and  just 
as  difficult  to  answer  them  categorically.  Take  the  most  definite  of  all,  lead  ; 
does  it  indeed  act  directly  on  the  arterial  media,  or  only  through  the  renal  lesions 
which  it  causes  ?  Perhaps  the  way  to  approach  this  from  the  prognostic  view- 
point may  best  be  illustrated  by  examples  of  the  two  extremes.  A  young  man 
with  abnormally  palpable  arteries,  but  no  evidence  of  renal  disease,  may  look 
forward  with  confidence  to  the  future  if  he  be  removed  forthwith  from  the  risk 
of  further  poisoning.  On  the  other  hand,  a  man  of  sixty,  with  pronounced 
arteriosclerosis  and  quite  definite  signs  of  renal  lesion,  cannot  expect  any  great 
improvement  in  his  outlook,  even  though  he  leave  his  injurious  work  forthwith. 
This  is  tantamount  to  saying  that  the  prognosis  in  a  case  of  plumbism  depends 
not  merely  on  arterial,  but  also  on  other,  lesions  ;  but  that  so  far  as  the  arterial 
changes  are  concerned,  the  fact  that  the  cause  is  one  where  further  operations 
can  be  prevented  is  all  in  favour  of  the  patient. 

Of  other  definite  chemical  substances  known  or  thought  to  act  deleteriously  on 
the  arterial  media,  two  of  the  luxuries  of  life  come  instantly  to  the  mind,  alcohol 
and  tobacco.  There  is,  at  the  present  time,  a  tendency  to  behttle  the  part  played 
by  alcohol  in  the  processes  of  arterial  disease  ;  none  the  less,  it  is  fair  to  console 
the  arteriosclerotic  patient,  whose  alcohohc  excesses  have  been  noteworthy,  with 
the  assurance  that  abstinence  will  be  good  for  his  arteries  ;  yet  it  is  probable 
that  the  effect  on  the  outlook  is  not  great.  As  for  tobacco,  it  is  very  difficult  to 
see  dayhght  here.  On  the  one  hand,  we  have  the  well-known  effect  of  nicotine 
on  the  arterial  walls — a  fact  which  Josue  and  others  have  used  experimentally 
to  such  good  purpose — backed  up  by  many  clinical  experiences  of  coincidence 
between  arterial  disease  and  excess  in  tobacco  ;  on  the  other  hand,  there  must 
be  reckoned  statements  like  those  of  Herz,  of  Vienna,  who  made  a  collective 
inquiry  into  the  etiology  of  arteriosclerosis  in  Austria,  and  found  that  the  disease 
was  not  particularly  common,  even  in  districts  where  the  women  smoke  pipes, 
and  the  habit  begins  in  childhood.  It  is,  at  any  rate,  permissible  to  forecast  a 
good  effect  from  cessation  or  moderation  of  smoking,  where  this  has  been  exces- 
sive and  no  other  factor  is  definitely  discernible.  The  same  may  be  said  of  tea- 
drinking  in  excess. 

Passing  from  these  poisons,  we  come  to  those  of  definite  bacterial  origin. 
Among  these,  typhoid  fever  stands  out  prominently.     Councilman's  researches 

6 


82  INDEX     OF     PROGNOSIS 

showed  that  the  arteries  of  persons  who  have  had  this  disease  are  thicker  than 
those  of  persons  who  have  not.  In  sjrphihs,  again,  a  similar  change  may  be 
observed,  quite  apart  from  the  local  arteritis  which  is  provoked  by  this  infection. 
If,  therefore,  we  find  evidences  of  early  arterial  degeneration  in  a  comparatively 
3-oung  subject  who  has  had  typhoid  fever,  their  significance,  so  far  as  length  of 
life  is  concerned,  is  probably  shght ;  that  which  caused  them  is  no  longer  operative 
(always  supposing  there  is  no  reason  to  believe  the  infection  to  be  persistent). 
In  the  case  of  the  syphihtic,  on  the  other  hand,  the  outlook  is  less  reassuring,  for 
it  is  not  easy  to  be  sure  that  the  infection  is  no  longer  active.  If  the  patient 
underwent  thorough  treatment,  and  if  the  Wassermann  reaction  be  negative,  it 
is  probable  that  syphiUs  is  no  longer  operative  as  a  cause  of  arteriosclerosis,  the 
prognosis  being  good  so  far  as  this  factor  is  concerned.  Of  the  other  infections 
we  know  less,  and  they  do  not  enter  into  the  assessment  of  expectation  of  life  in 
arteriosclerosis. 

Yet  another  group  of  toxic  agencies  has  to  be  considered,  those  of  endogenous 
origin.  Certain  of  these,  which  are  relatively  definite,  may  be  considered  first. 
Arterial  disease  is  associated  with  glycosuria,  and  here  the  cause  overshadows 
the  effect,  so  far  as  prognosis  is  concerned  ;  we  do  not  estimate  the  chances  of  our 
glycosuric  patient  in  terms  of  his  arteries,  but  in  terms  of  his  output  of  sugar  and 
the  degree  to  which  this  can  be  controlled.  It  may,  however,  be  remarked  that 
the  progress  of  arterial  change  in  such  persons  is  relatively  slow,  and  that  the 
outlook  is  therefore  better  than  in  some  types  of  arterial  degeneration.  Mitchell 
Bruce  found  that  cardiovascular  degeneration  in  glycosuria  ran  an  average 
course  of  over  twelve  years  from  the  onset  of  symptoms.  That  gout  plays  a 
part  in  causing  aii:eriosclerosis  is  also  clearly  proved.  If,  therefore,  an  arterio- 
sclerotic patient  be  definitely  gouty,  and  other  causal  factors  are  not  apparent, 
the  prognosis  varies  according  to  the  amenability  of  the  parent  disorder ; 
should  the  gout  yield  to  dietetic  and  other  measures,  the  arterial  changes  will 
progress  but  slowly.  These  are  well-defined  morbid  entities  ;  but  they  merge 
insensibly  into  other  categories  which  are  not  so  easy  to  understand — those  of 
renal  disease,  mental  and  muscular  stress,  over-eating,  and  hypertension.  So 
far  as  this  article  is  concerned,  the  last  of  these  may  be  dismissed  in  a  word  or 
two  ;  high  tension  is  not  a  disease,  but  a  symptom  arising  from  a  variety  of 
causes,  and  when  it  coincides  with  arteriosclerosis,  it  is  probable  that  the  two 
constitute  different  aspects,  the  one  anatomical  and  the  other  physiological,  of 
one  and  the  same  process.  In  any  event,  it  is  more  convenient  to  consider  such 
cases  under  the  caption  of  high  tension,  as  I  have  done  in  the  articles  in  this  book. 
Arteriosclerosis  as  complicating  renal  disease  will  also  be  considered  under  the 
same  heading.  It  is  not  quite  proper,  however,  to  dismiss  all  the  factors  named 
above  in  this  way ;  for  though  arteriosclerosis  is  seldom  provoked  by  over-eating 
or  stress,  apart  from  high  tension,  yet  this  latter  may  be  relatively  shght,  and 
the  arterial  change  comparatively  prominent.  Excess  in  food  is  an  extremely 
common  and  important  cause  of  arterial  degeneration  ;  this  is  often  apparent 
in  persons  who  eat  large  masses  of  food  in  general,  and  red  meat  in  particular. 
There  is  no  factor  which  can  be  cut  out  with  greater  confidence  of  bringing  about 
improvement  in  the  patient's  condition ;  consequently,  the  arteriosclerotic 
person  who  over-eats,  and  yet  consents  to  a  genuine  correction  of  his  evil 
ways,  stands  a  far  better  chance  than  one  who  is  incorrigible.  As  to  stress, 
it  is  pretty  clear  that  it  is  mental  and  not  physical  overstrain  that  tells  ;  indeed, 
as  French  has  suggested,  much  of  the  premature  arterial  decay  of  city  men  is  to 
be  referred  to  overwork  of  some  arteries  (cerebral  and  ahmentar^'),  in  contrast 
•with  underwork  of  those  supplying  the  skeletal  muscles  ;  and  if  such  persons 
can  be  persuaded  to  work  and  eat  less,  and  to  take  regular  physical  exercise,  the 


ARTERIOSCLEROSIS  83 

prognosis  is  thereby  ameliorated.  Finally,  it  is  possible  to  analyze  the  stress 
factor  a  little  further,  for  Mitchell  Bruce  distinguishes  between  emotional  and 
intellectual  expenditure,  and  finds  that  it  is  the  former  that  is  especially  hard  on 
the  arteries.  Now  this  brings  us  to  the  furthest  point  to  which  it  is  legitimate 
to  press  the  toxic  analogy  ;  it  is  probable  that  over-eating  causes  arteriosclerosis 
through  the  agency  of  toxins,  and  it  is  possible  that  stress,  even  of  the  emotions, 
acts  in  the  same  way,  but  it  is  also  very  certain  that  emotional  strain  is  a  matter 
of  temperament.  Here  we  come  to  the  fact  that  there  are  cases  of  arterio- 
sclerosis in  which  it  is  possible  to  tell  the  patient  that  it  is  folly  to  continue  to 
live  as  he  is  living — over-eating,  under-exercised,  constantly  devoured  by  anxiety 
and  excitement, — and  to  say  that  if  these  causes  be  removed  his  life  will  be 
prolonged,  and  arterial  decay  slowed  down  :  and  yet  the  patient  may  be  so 
constituted  temperamientaliy  that  he  simply  cannot  stop.  He  may  amend  his 
diet ;  he  may  even  lessen  his  work  and  take  to  golf  ;  but  he  cannot  stop  worry- 
ing. Hence,  temperament  is  an  important  etiological  factor  in  the  prognosis  of 
arteriosclerosis  ;  it  is  a  potent  cause,  and  yet,  at  the  same  time,  one  which  cannot 
be  done  away  with,  any  more  than  it  is  possible  for  the  Ethiopian  to  change  his 
skin.  In  people  of  the  worrying,  anxious  kind,  therefore,  arteriosclerotic 
changes  are  less  easily  checked,  and,  on  that  account,  of  graver  import  than  in 
persons  who  take  life  quietly,  and  who  will  readily  consent  to  profound  altera- 
tions in  their  manner  of  living. 

Summing  up  what  has  been  said  as  to  the  importance  of  etiology  in  prognosis, 
we  find  that  arteriosclerosis  is  more  likely  to  run  a  favourable  course  if  it  is 
largely  dependent  on  some  causal  factor  which  can  be  removed. 

2.  Stage  of  Development. — -A  second  factor  of  importance,  in  arriving  at  a 
forecast  of  the  future  awaiting  the  arteriosclerotic  person,  is  the  stage  at  which 
it  is  first  found  that  the  vessels  are  not  normal.  It  is  tempting  to  divide  the 
progress  of  arteriosclerosis  into  chapters,  but  this  is  of  no  value  so  far  as  our 
present  purpose  is  concerned  ;  and  the  importance  of  the  epoch  at  which  the 
arteriosclerotic  patient  comes  under  observation  is  best  realized  by  contrasting 
the  outlook  at  the  two  extremes  of  the  malady.  Ignoring  for  the  present  the 
pre-sclerotic  stage  of  Huchard,  which  is  best  considered  under  the  caption  of  high 
blood-pressure,  we  find  that  the  earliest  stage  of  arteriosclerosis  to  come  under 
notice  is  that  in  which  thickening  of  the  vessels  is  encountered  accidentally,  in 
persons  who  present  themselves  for  examination  on  account  of  other  symptoms 
or  reasons.  In  such  cases,  there  are  no  subjective  evidences  of  arterial  disease, 
or,  at  least,  none  that  have  struck  the  patient  as  noteworthy.  Now,  it  would  be 
rash  in  the  extreme  to  offer  a  prognosis  in  such  cases  ;  as  a  rule  none  is  asked  for, 
and  even  when  it  is,  it  is  seldom  that  one  can  give  an  opinion  that  is  of  much 
value.  In  extreme  cases,  the  gravity  of  the  outlook  is  easily  perceived:  e.g.,  in 
a  patient  of  forty  who  has  arteries  thicker  than  most  men  of  sixty,  and  whose  fore- 
bears have  died  young.  Here  the  prognosis  is  clearly  bad  enough  to  justify  a 
statement  to  that  effect,  if  the  physician  thinks  any  good  can  be  done  by  it  ;  if 
any  contributory  cause  can  be  traced,  such  as  excess  in  meat,  it  may,  indeed,  have  _ 
a  salutary  effect  on  the  patient  if  the  prospects  be  hinted  at,  together  with  the 
amelioration  that  is  likely  to  accrue  from  a  reform  of  the  diet.  But  in  the 
majority  of  such  cases,  if  we  are  asked  for  an  opinion  as  to  the  patient's  future 
by  himself  or  his  friends,  and  we  have  no  evidences  of  arteriosclerosis  apart  from 
what  can  be  felt  with  the  finger,  it  is  possible  only  to  say  frankly  that  the  vessels 
are  thicker  than  they  ought  to  be  ;  that  this  is  by  no  means  a  certain  sign  of 
curtailment  of  the  expectation  of  life  ;  and  that  reasonable  living  is  even  more 
necessary  than  in  the  average  individual,  since  this  alone  can  avert  such  menace 
as  is  implied  in  the  existence  of  arterial  change.     Sometimes  it  is  possible  to  form 


84  INDEX     OF     PROGNOSIS 

a  rather  more  accurate  opinion  of  the  patient's  chances  by  seeing  him  several 
times,  at  fairly  long  intervals,  e.g.,  six  months  ;  if  such  systematic  observations 
enable  one  to  detect  the  beginnings  of  visceral  change,  as  a  result  of  the  arterial 
lesion,  the  task  of  prognosis  is  clarified. 

At  the  other  extreme  of  the  sclerotic  process,  the  patient  comes  under  observa- 
tion suffering  from  the  organic  effects  of  the  disease.  Of  these  effects,  three 
stand  out  pre-eminent  :  cardiac  failure,  softening  of  the  brain,  and  peripheral 
gangrene.  Each  of  these  will  be  considered  under  its  appropriate  heading,  so 
that  we  need  not  regard  them  in  detail,  or  from  any  point  of  view  other  than  that 
of  arteriosclerotic  phenomena.  From  this  standpoint,  their  importance  is  that 
they  prove  the  disease  to  have  reached  an  extreme  stage — so  extreme,  that  the 
vessels  no  longer  perform  their  function  of  supplying  nourishment  to  the  organs 
dependent  on  them.  Now  the  principle  running  through  the  whole  prognosis  of 
arteriosclerosis  is  its  incurability  ;  the  disease  may  be  retarded,  possibly  arrested, 
but  it  is  impossible  to  put  the  clock  back.  It  follows,  then,  that  these  pheno- 
mena are  evidences  of  the  final  development  of  incurable  arterial  disease  ;  and 
the  prognosis,  so  far,  at  all  events,  as  the  injured  parts  are  concerned,  is  unre- 
servedly bad. 

Between  these  two  extremes  there  are  all  shades  of  cases  in  which  there  are 
symptoms  referable  to  arterial  disease.  From  the  prognostic  standpoint,  these 
are  chiefly  of  importance  in  so  far  as  they  prove  that  the  disease  has  reached  a 
stage  at  which  it  interferes  Avith  the  nutrition  of  the  parts  supplied.  Some  of 
these  phenomena  are  of  special  interest,  and  may  therefore  be  considered  in 
detail.  The  simplest  to  understand  is  transient  dyskinesia  of  the  limbs.  The 
most  familiar  form  of  this  is  seen  in  the  lower  limb — an  intermittent  limp  ;  the 
legs  are  comfortable  while  at  rest,  and  able  to  carry  their  owner  for  short 
distances,  but  after  a  walk  of  varying  distance  cramps  come  on,  and  the  limb 
suddenly  gives  way,  sometimes  so  suddenly  that  the  patient  falls  to  the  ground. 
Similar  troubles  may  afflict  the  arm,  rendering  it  painful  and  useless  when  it  is 
put  to  the  performance  of  unusual  tasks.  Such  phenomena  are,  perhaps,  most 
clearly  seen  in  obhterative  arteritis  (q.v.),  but  they  do  also  occur  in  connection 
with  ordinary  arteriosclerosis.  Their  significance  lies  in  the  unmistakable 
evidence  which  they  afford  that  the  arterial  disease  has  reached  an  advanced 
stage,  and  that  absolute  occlusion  is  not  far  off.  Attacks  which  are  probably 
similar  in  origin  are  seen  in  connection  with  the  brain  ;  such  are  transient  hemi- 
anopia,  squint,  aphasia,  and  even  hemiplegia.  These  are  to  be  regarded  as 
evidences  of  advanced  arterial  disease,  and  as  premonitions  of  permanent  injury 
to  the  substance  of  the  brain.  The  same  may  be  said  of  angina  pectoris,  and  the 
less  definite  grades  of  cardiac  pain  ;  the  coronary  channels  are  becoming  inade- 
quate to  their  duty  of  supplying  blood  to  the  myocardium.  Attacks  of  abdo- 
minal pain,  with  meteorism,  have  been  described  as  '  abdominal  angina,'  and 
referred  to  disease  of  the  mesenteric  vessels.  All  these  paroxysmal  phenomena 
are  therefore  of  the  gravest  import,  for  they  bespeak  a  stage  of  arterial  disease 
which  can  scarcely  go  further  without  permanently  cutting  off  the  blood  from 
the  parts  which  the  arteries  supply. 

Apart  from  such  attacks,  however,  there  are  less  striking  symptoms  which, 
none  the  less,  surely  portend  advance  in  the  arteriosclerotic  process  to  the  point 
at  which  adequate  blood-supply  is  threatened.  Such  are  vertigo,  stumbhng 
speech,  slowed  cerebration,  persistent  headache,  and  sleeplessness  ;  breathless- 
ness  on  exertion,  puf&ness  of  the  ankles,  and  muffling  of  the  cardiac  sounds  ; 
impairment  of  sensation  in  the  periphery  of  the  limbs,  and  increasing  muscular 
weakness.  All  these  are  to  be  interpreted  as  signs  of  progressive  arterial  degener- 
ation when  they  are  associated  wdth  palpable  thickening  of  the  surface  arteries  ; 


ARTHRITIS,     TUBERCULOUS  85 


and,  as  such,  they  add  to  the  gravity  of  the  prognosis,  for  they  show  that  the 
disease  is  becoming  effective  as  a  hindrance  to  the  proper  nutrition  of  the  organs 
and  tissues  of  the  body. 

Summing  up  what  has  been  said  as  to  the  significance  of  the  stage  of  the  disease 
in  regard  to  prognosis,  we  find  that  arteriosclerosis  tends  to  progress  towards  the 
point  at  which  it  cuts  off  blood-supply  from  certain  parts  of  the  body  ;  and  that 
we  must  be  on  the  look-out  for  evidences  of  the  earlier  phases  of  this  interference 
with  nutrition. 

3.  Distribution. — One  other  aspect  of  the  disease  must  be  taken  into  account 
in  working  out  the  prognosis  of  any  given  case,  namely,  the  distribution  of  the 
arterial  changes.  It  is  obvious  that  these  are  of  much  greater  significance 
when  they  attack  the  vessels  responsible  for  nourishing  a  vital  organ,  such  as 
the  brain,  than  when  it  is  the  leg  that  is  threatened.  Arteriosclerotic  lesions  of 
the  brain  are  more  hopeless  in  regard  to  recovery  than  any  others  ;  even  in  the 
most  favourable  cases  of  cerebral  thrombosis  of  the  senile  type,  the  patient  is 
never  quite  the  same  again,  and  usually  his  downfall  is  progressive  and 
resistless.  The  cardiac  lesions  are  less  hopeless,  perhaps,  but  more  dangerous 
to  life.  Distinct  evidences  of  abdominal  arteriosclerosis  are  rare  at  any  stage, 
and  the  data  on  which  to  base  a  general  statement  are,  therefore,  scanty  ;  but 
it  can  be  safely  said  that  such  phenomena  as  do  point  to  this  form  of  the 
disease  are  only  very  rarely  followed  by  grave  consequences,  such  as  mesenteric 
thrombosis. 

A  last  remark  is  this  :  that  a  calamity  due  to  arterial  degeneration  in  one  part 
of  the  body  predisposes  to  the  occurrence  of  others.  The  most  conspicuous 
example  of  this  association  is  seen  in  the  cerebral  symptoms  which  are  apt  to 
follow  close  on  cardiac  breakdown  due  to  arterial  disease.  Rest  in  bed  pulls  the 
heart  through,  but  the  brain  remains  injured. 

Summary. — In  any  individual  case  of  arteriosclerosis,  the  factors  to  be  con- 
sidered are  :  (i)  The  patient's  arterial  heritage  ;  (2)  The  presence  of  toxic  or 
stress  causes,  and  the  possibility  of  their  removal ;  (3)  The  stage  of  the  disease  ; 
(4)  Its  distribution.  Carey  F.  Coombs. 

ARTHRITIS,  SEPTIC. — {See  Joints,  Injuries  of.) 

ARTHRITIS,  TUBERCULOUS. — We  shall  first  examine  some  general  con- 
siderations in  the  prognosis  of  tuberculous  joint  disease,  and  then  discuss  the 
end-results  of  the  various  methods  of  treatment  for  particular  joints. 

General  Outlook. — The  following  factors  are  of  great  importance  in  arriving 
at  an  accurate  prognosis  :  The  age  of  the  patient ;  the  presence  of  phthisis  or 
other  lesions  elsewhere  ;  the  presence  of  septic  infection  ;  the  onset  of  acute 
general   tuberculosis  ;     the   social   position   and   carefulness   of   parents. 

With  regard  to  the  age,  we  may  say  generally  that  children  usually  recover, 
while  adults  show  Uttle  tendency  to  improvement  apart  from  excision  of  the 
joint,  except  in  mild,  early  cases  where  the  diagnosis  is  likely  to  be  precarious. 

Concerning  the  second  and  third  propositions,  no  comment  is  needed  except 
to  say  that  even  septic  sinuses  do  not  necessarily  make  the  prospects  of  recovery 
hopeless.     Albuminoid  disease  is  now  rarely  seen. 

The  gravest  risk  is  that  of  acute  generalized  tuberculosis,  and  the  early  signs 
of  this,  such  as  fever  (not  accounted  for  by  the  state  of  the  joint),  vomiting, 
drowsiness,  etc.,  should  be  regarded  as  a  warning  that  the  end  may  be  near. 

In  early,  well-treated  cases,  restoration  of  a  movable  joint  is  occasionally  seen, 
but  this  is  the  exception  and  not  the  rule.  In  general,  there  is  more  or  less 
complete  fixation,  especially  if  septic  infection  has  supervened.  Further, 
tuberculous  hip  leads,  in  many  cases,  to  very  decided  shortening  of  the  limb. 


86 


INDEX     OF     PROGNOSIS 


Although  the  majority  of  patients  with  a  tuberculous  joint  eventually  get 
'  cured,'  it  is  important  to  realize  the  limitations  with  which  the  word  should 
be  used.  Even  when  there  is  no  pain,  swelhng,  or  other  symptom  for  years,  it 
by  no  means  proves  that  the  bacilh  are  all  dead.  Strain,  pregnancy  or  lactation, 
forcible  bending  of  the  joint  by  a  bone-setter,  or  much  more  trivial  causes,  may 
lead  to  a  recrudescence  of  the  trouble. 

Hip-joint. — A  few  years  ago,  the  eventual  mortality  of  this  disease  was  put 
at  30  per  cent,  but  nowadays  it  is  undoubtedly  less.  Watson  Cheyne  found  a 
death-rate  of  12  per  cent  in  77  cases,  but  some  of  the  patients  had  phthisis  ; 
excluding  these,  the  fatalities  amounted  to  8  per  cent.  No  cases  were  fatal 
which  were  aseptic  throughout. 

The  duration  of  treatment  must  be  long.  Thomas  used  to  estimate  that  it 
took  seven  years  to  cure  with  his  splint ;  Cheyne  considers  this  excessive.  The 
amount  of  shortening  is  usually  about  one  and  a  half  inches  ;  it  depends,  of 
course,  on  the  stage  at  which  the  disease  can  be  brought  to  a  standstill ;  there 
will  be  no  permanent  shortening  in  quite  early  cases. 

The  prognosis  in  relation  to  treatment  is  very  important.  Some  evidence  was 
advanced  at  a  recent  debate  of  the  Royal  Society  of  Medicine  that  tuberculin  is 
helpful ;  Butler  Harris  reported  10  cases  improved  by  it ;  Maynard  Smith 
quoted  19,  of  which  16  were  previously  doing  badly,  where  tuberculin  rapidly 
improved  all  except  3. 

There  is  no  doubt  that,  given  prolonged  earlj^  treatment  in  special  institutions, 
the  immense  majority  of  children  with  tuberculous  hips  can  be  cured  without 
operation,  and  may  recover  a  fairly  useful  limb.  Of  150  cases  at  the  New  York 
Cripple  Hospital,  107  were  cured  with  little  or  no  deformity,  although  excision 
was  only  performed  4  times.  At  the  Alexandra  Hospital,  London,  900  cases 
were  treated  without  excision,  and  only  4  died  (Bowlbj^).  Gauvain  reported  a 
long  series  treated  without  operation  at  the  Alton  country  cripple  home  with 
excellent  results  ;   of  336  cases  of  tuberculosis  of  various  joints,  only  i  died. 

Of  course,  it  is  not  possible  to  obtain  results  as  good  as  these  by  conservative 
measures  in  ordinary  hospital  practice ;  but  very  few  British  surgeons  are  disposed 
to  regard  excision  with  favour  at  the  present  time,  except,  perhaps,  in  adults. 

Stiles,  one  of  the  principal  supporters  of  the  formal  excision,  gives  his  results 
in  the  following  table  : — 

Results  of  Excision  for  Tuberculosis  (Stiles.) 


Joint 

Excisions 

Good 

Useful 

Bad 

Am- 
putated 

Deaths 

Not 
traced 

Hip    - 
Knee  - 
Elbow 
Ankle 

60 
64 
54 
29 

19 

24 

10 

9 

4 

5 

15 

4 

3 

1 
1 

1 

3 

12 
1 
6 

12 
4 
6 
3 

19 

18 

21 

6 

Total 

207 

62 

28 

6 

22 

25 

64 

It  will  be  seen  that  the  death-rate,  immediate  and  remote,  is  high  ;  most  of 
the  fatalities  were  due  to  generahzed  tuberculosis.  Stiles's  cases  were  all  children. 
The  average  shortening  was  one  and  three-quarter  inches  ;  the  maximum  was 
five  and  a  half  inches.  Of  the  cases  followed  through,  23  out  of  40  got  a  good  or 
useful  Umb. 


ARTHRITIS,     TUBERCULOUS  87 


Thompson  gives  results  of  40  cases  operated  on  at  Guy's  Hospital  between 
1896  and  1903  ;  eventually,  6  of  these  died  and  8  required  amputation,  so  that 
35  per  cent  were  a  failure  ;  in  11  cases  sinuses  were  still  present ;  in  15  the  disease 
had  become  inactive.  Deformity  was  usually  marked,  but  utility  good  ;  there 
were  13  fixed  joints,  to  mobile,  and  i  flail-like.     Seven  were  earning  fair  wages. 

We  may  conclude,  therefore,  that,  after  excision,  a  good  result  is  likely  to  be 
obtained  in  only  about  half  the  cases. 

There  is,  again,  a  very  real  danger  of  lighting  up  fatal  acute  miliary  tubercu- 
losis. Death  took  place  from  this  cause,  soon  after  the  operation,  in  2  of  Stiles's 
and  3  of  Watson  Cheyne's  cases.  Konig  has  shown  that,  out  of  18  patients  with 
tuberculous  hip  who  died  of  meningitis,  death  followed  operation  in  16. 

Knee-joint. — Figures  relating  to  the  prognosis  of  tuberculosis  of  the  knee-joint 
treated  conservatively  do  not  appear  to  be  available ;  but  a  general  opinion  may 
be  expressed  that  the  prospects  as  to  life  are  better  than  in  tuberculosis  of  the 
hip,  but  the  prospects  as  to  local  recovery  scarcely  so  good.  In  adults,  if  there 
is  well-marked  swelling,  and  evidence  of  extensive  disease  in  and  about  the 
joint,  the  prospects  of  recovery,  apart  from  operation,  are  not  promising  ;  but 
mild  early  cases  without  much  pulpy  swelling  often  do  well.  In  Carre's  clinic 
at  Breslau  and  Bonn,  the  end-results  of  86  cases  treated  conservatively  (rest, 
heliotherapy,  and  iodoform  injections)  have  been  published  by  Els.  Two-fifths 
of  the  patients  were  under  ten  years  of  age.  Approximately  half  (51  per  cent) 
obtained  a  good  result  ;    45  per  cent  were  not  satisfactory,  and  the  rest  died. 

We  have  some  statistical  evidence  concerning  the  end-results  of  excision,  both 
in  children  and  adults.  Stiles  performs  excision  in  children  whenever  the 
articular  cartilages  appear  to  be  destroyed,  or  an  abscess  forms  outside  the  joint. 
Arthrectomy  is  falling  into  disrepute,  because  the  joint  produced  may  be  weak 
and  painful. 

It  will  be  observed  that  in  63  operations  there  were  4  deaths,  one  withm  a 
month  from  generalized  tuberculosis,  and  the  others  later  ;  i  death  was  from 
measles.  Of  45  cases  followed  through,  29  got  a  '  good  '  or  '  useful  '  result,  but 
subsequent  amputation  was  necessary  in  12.  Of  30  joints  examined,  29  were 
fixed  and  i  slightly  mobile. 

The  two  principal  troubles  are  shortening  and  flexion.  The  average  amount 
of  shortening  was  a  little  over  two  inches  ;  in  5  cases  it  exceeded  three  inches  ; 
a  little  shortening,  up  to  one  and  a  quarter  inches,  does  not  necessitate  a  high 
boot.  In  5  cases  a  subsequent  wedge-shaped  resection  was  necessary  on  account 
of  angular  deformity,  and  in  another  there  was  flexion  to  ninety  degrees.  The 
results  are  not  always  as  good  as  this.  Elmslie,  in  a  study  of  89  cases  of  excision 
of  the  knee,  found  3  with  over  six  and  a  half  inches  of  shortening  and  marked 
angulation,  25  had  been  subjected  to  re-excision,  and  3  to  a  third  excision. 

The  results  of  excision  in  adults  have  been  pubhshed  by  Seldowitsch,  of  St. 
Petersburg,  as  follows.  In  57  cases  followed  through  :  35  obtained  firm,  painless, 
bony  ankylosis  with  excellent  function  ;  10  were  improved  ;  2  were  no  better  ; 
4  had  subsequently  to  be  amputated  ;  6  died  (pneumonia  2,  general  buberculosis 
2,  meningitis  i,  cachexia  i). 

In  the  Breslau  and  Bonn  series,  excision  was  performed  in  268  cases  (114  under 
fifteen),  the  indications  being  evidence  of  bony  disease  complicated  by  abscesses 
or  fistulas  or  severe  contractures  or  luxations.  The  immediate  results  showed 
2  per  cent  deaths,  88  per  cent  recoveries,  6  per  cent  little  or  no  better,  and  4  per 
cent  needing  amputation.  Examined  a  year  later,  out  of  188  cases,  14  had 
died,  but  84  per  cent  showed  a  good  result. 

We  may  conclude,  therefore,  that  after  excision  for  tuberculosis  of  the  knee, 
about  two-thirds,  both  children  and  adults,  get  a  very  good  result,  rather  better 


INDEX     OF     PROGNOSIS 


in  adults  than  children  ;    but  that  great  skill  and  care  are  necessary  in  children, 

or  the  results  may  be  deplorable.     The  mortality,  immediate  and  remote,  is 
about  8  per  cent. 

Ankle  and  Foot. — In  Stiles's  series,  29  ankles  were  excised,  3  dying  subse- 
quently. Out  of  23  followed,  13  got  a  '  good  '  or  '  useful '  ankle,  and  6  required 
amputation.     The  average  shortening  was  three-quarters  of  an  inch. 

Syring  has  published  the  results  of  a  series  of  222  cases  of  tuberculosis  of  the 
foot  and  ankle  treated  in  Garre's  cUnic  at  Breslau  and  Bonn,  tabulated  for  the 
1913  Congress.  Conservative  measures  similar  to  those  mentioned  above  for 
the  knee-joint  had  to  be  given  up  in  114  cases,  but  in  the  remaining  108  they 
gave  good  results  in  75  per  cent,  that  is,  about  a  third  of  the  whole.  Excision 
of  the  astragalus  was  adopted  in  75  cases,  of  which  49  obtained  a  good,  often  a 
very  good,  result.  The  prospects  of  success  are  much  better  in  children  than  in 
adults,  but  even  over  twenty  years  of  age  the  majority  did  well.  Amputation 
was  necessary  on  45  occasions  ;  of  these,  30  were  soon  able  to  return  to  work. 

We  may  conclude,  therefore,  that  conservative  treatment  of  the  foot  and 
ankle  may  succeed  in  about  a  third  of  the  cases,  and  excision  in  about  two- 
thirds. 

Shoulder-joint. — Evidence  concerning  the  exact  prognosis  is  not  forthcoming. 
Stiles  operated  on  so  few  cases  that  he  gives  no  figures.  The  majority  of  the  cases 
occur  in  adults,  and  so  it  is  not  usually  worth  while  to  try  prolonged  rest,  which 
may  not  succeed  after  all.  Watson  Cheyne,  therefore,  advocates  excision  in 
adults,  except  in  mild  early  cases.  A  fairly  mobile  useful  shoulder  generally 
results,  and  the  period  of  disabiUty  is  very  greatly  shortened. 

Elbow-joint. — Here  the  usefulness  of  the  arm  depends  very  much  upon  the 
position  ;  ankylosis  at  a  wide  angle  is  most  inconvenient.  In  practice,  a  more 
useful  joint  is  usually  to  be  obtained  by  early  operation,  which  will  probably 
ensure  mobility.  This  is  especially  true  if  abscesses  or  sinuses  are  present, 
because,  in  that  case,  very  prolonged  fixation  would  be  necessary  to  get  a  cure 
by  conservative  means.  According  to  figures  quoted  by  Watson  Cheyne,  75  per 
cent  of  the  patients  treated  by  excision  get  a  good  joint,  and  the  remaining 
quarter  may  have  a  stiff  or  a  flail  joint  in  about  equal  proportions. 

Stiles  excised  the  elbow  54  times  ;  6  patients  died  subsequently  (three  months 
to  two  and  a  half  years)  of  generahzed  tuberculosis.  Apart  from  these,  25  out 
of  27  obtained  a  '  good  '  or  '  useful  '  joint  ;  in  10  there  was  considerable 
power  and  mobility,  in  6  ankylosis,  and  7  were  flail.  The  shortening  averaged 
one  and  a  half  inches.     Only  i  patient  required  subsequent  amputation. 

Wrist-joint. — In  children,  with  proper  conservative  treatment,  these  cases 
practically  all  get  well,  mth  some  permanent  stiffness  (Marsh).  In  adults,  also, 
the  patient  is  likely  to  get  the  best  results  by  prolonged  fixation,  except  when  the 
whole  joint  is  badly  disorganized,  with  septic  sinuses.  The  hand  left  after 
excision  is  usually  much  crippled  on  account  of  the  shortening  of  the  bones 
compared  with  the  tendons,  and  amputation  is  often  preferable.  Exact  figures 
are  not  available. 

Dactylitis. — In  children,  in  the  great  majority  of  cases,  fixation  and  conserva- 
tive treatment  end  in  a  cure  (Cheyne).  Amputation  is  seldom  required.  In 
adults,  the  course  is  so  slow  and  the  prospect  of  benefit  so  uncertain  that 
amputation  is  to  be  preferred. 

Saero-iliac  Disease. — Although  exact  figures  cannot  be  quoted,  it  is  generally 
admitted  that  the  prognosis  in  this  afiection  is  grave.  Most  of  the  cases  occur 
in  adults,  and  phthisis  is  often  present.  The  great  majority  die,  after  a  chronic 
illness.  In  young  subjects,  recovery  may  occur,  but  often  ^vith  obUque  deformity 
of  the  pelvis  (Cheyne). 


ASCITES  89 

Wheeler,  of  Dublin,  points  out  that  better  results  may  be  obtained  by  earher 
diagnosis,  and  that  the  sciatica  and  gluteal  pain,  together  with  a  skiagram,  give 
definite  evidence  before  the  classical  signs  develop.  He  obtained  an  excellent 
result  by  early  operation  in  one  case,  and  a  fair  result  in  another. 

References. — Watson  Cheyne,  Tuberculous  Disease  of  Bones  and  Joints ;  Stiles, 
Brit.  Med.  Jour.  1912,  ii,  1356  (and  discussion)  ;  Marsh,  Joint  Diseases  ;  Proc.  Roy. 
Soc.  Med.  1912,  discussion,  Children's  Section,  65,  76  ;  Sever,  Jour.  Amer.  Med.  Assoc. 
1910,  2128  ;  Thompson,  Guy's  Hasp.  Rep.  1905  ;  Els,  Beitr.  z.  klin.  Chir.  1913,  Ixxxvii, 
51  ;  Syring,  Ibid.   88.  A.  Rendle  Short. 

ASCITES.— Since  ascites  is  not  a  disease,  but  the  result  of  various  patho- 
logical conditions,  its  prognostic  significance  in  any  given  case  depends  on  its 
cause.  As,  however,  it  may  be  a  late  or  even  terminal  phenomenon  in  some 
conditions,  its  recognition  renders  the  prognosis  of  the  causal  disease  very  grave. 
The  commonest  condition  associated  with  ascites  is  some  form  of  heart  disease  ; 
out  of  224  cases  in  which  a  quart  or  more  of  ascitic  fluid  was  found  after  death, 
89,  or  39  per  cent,  were  due  to  cardiac  disease,  the  next  most  important 
cause  being  some  form  of  intra-abdominal  new  growth,  in  44,  or  19-6  per 
cent  (Cabot^).  In  adherent  pericardium,  ascites  may  be  due  to  chronic 
peritonitis  (polyorrhymenitis) ,  and  then  persists  for  long  periods  ;  but  in  ordinary 
cases  of  chronic  cardiac  failure,  the  onset  of  ascites  shows  that  the  disease  has 
reached  an  advanced  stage.  Again,  in  portal  and  hypertrophic  biliary  cirrhosis 
of  the  liver,  in  chronic  splenic  anaemia  thus  constituting  Banti's  disease,  and  in 
chronic  malaria,  the  advent  of  ascites  is  a  very  grave  indication.  That  the 
prognosis  of  ascites  depends  on  the  cause  is  shown  by  the  different  outlook 
in  ascites  due  to  malignant  disease  and  to  tuberculosis  of  the  peritoneum 
respectively.  The  various  forms  of  ascites  are  referred  to  incidentally  throughout 
this  article,  but  some  of  the  more  important  forms  will  now  be  mentioned  briefly. 

The  three  conditions — uncomplicated  cirrhosis,  cirrhosis  complicated  by 
simple  chronic  peritonitis,  and  simple  chronic  peritonitis — stand  in  this  order 
as  regards  the  gravity  of  the  prognosis.  Thus  the  average  duration  of  life  after 
the  appearance  of  ascites  in  thirty-one  cases  of  uncomplicated  cirrhosis  was  188 
days  ;  in  twelve  cases  of  cirrhosis  complicated  with  simple  chronic  peritonitis, 
288  days  ;  and  in  nine  cases  of  uncomplicated  simple  chronic  peritonitis,  624 
days  (Ramsbottom^).  In  the  ascitic  form  of  tuberculous  peritonitis,  the  outlook 
is  better  than  in  all  other  forms  of  ascites  except  those  associated  with  the 
presence  of  an  innocent  uterine  or  ovarian  tumour  which  can  be  removed.  The 
ascites  due  to  gummas  in  acquired  syphilis  of  the  liver  rapidly  diminishes  with- 
out tapping  under  efficient  treatment  with  iodides,  and  the  prognosis  is  good. 
But  in  the  rare  cases  of  ascites  due  to  inherited  syphilis,  whether  in  very  early 
life  or  later,  when  the  lesions  of  delayed  inherited  syphilis  (gummas,  cicatrices, 
and  lardaceous  disease)  have  developed,  the  outlook  is  very  serious.  As  men- 
tioned elsewhere  (see  Liver,  Cirrhosis  of),  cicatrices  and  so-called  syphilitic 
cirrhosis  are  not  influenced  by  antisyphilitic  remedies. 

Medical  Treatment. — The  influence  of  diuretics  on  the  prognosis  depends  on 
the  effect  they  exert  on  the  underlying  cause.  Thus,  they  may  diminish  or 
remove  the  ascites  by  improving  the  circulatory  conditions  in  the  cardiac  or 
cardio-renal  diseases  which  are  responsible  for  the  effusion,  though  even  here 
their  action  is  somewhat  capricious  and  uncertain  ;  but  in  chronic  peritonitis 
and  malignant  disease  of  the  peritoneum,  little  benefit  can  be  expected. 
Diuretics  are  disappointing  in  the  presence  of  considerable  ascites,  and  are  often 
more  effective  shortly  after  paracentesis,  when,  from  removal  of  pressure  on 
the  renal  veins,  the  kidneys  are  better  able  to  respond  to  stimulation. 


go  INDEX     OF     PROGNOSIS 

A  salt-free  diet  (dechlorinization)  is  more  likely  to  do  good  in  renal  cases, 
and  a  restricted  intake  of  iiuids  (dry  diet)  should  succeed  better  in  cardiac  and 
cardio-renal  ascites  than  in  other  forms.  Purgation  is  usually  disappointing, 
though  besides  removing  fluid  it  may  exert  a  detoxicating  action,  especially  in 
cirrhosis.  Excessive  purgation  may  seriously  impair  nutrition,  and  in  the  past 
such  vigorous  treatraent  may  have  hastened  the  end.  When  ascites  diminishes 
as  the  result  of  the  administration  of  iodides,  the  underlying  cause  is  almost 
certainly  syphilis,  and  the  prognosis  is  therefore  very  good. 

Operative  Treatment. — In  ascites  associated  with  innocent  ovarian  or  uterine 
tumours,  operation  renders  the  outlook  extremely  good  ;  but  this  association 
is  not  very  frequent.  Ascites  was  found  in  lo,  or  50  per  cent,  of  20  cases  of 
ovarian  fibroma,  in  31,  or  7-9  per  cent,  of  391  multilocular  ovarian  cysts,  and  in 
55,  or  7  per  cent,  of  uterine  fibromyomas  (Cabot^).  In  papilloma  of  the  ovary 
ascites  is  frequent.  In  all  these  conditions  removal  of  the  tumour  cures  the 
ascites,  and  Cabot^  points  out  that  it  may  also  cure  a  concomitant  pleural 
effusion. 

In  the  ascites  of  tuberculous  peritonitis  the  question  whether  simple 
laparotomy  or  medical  measures  give  the  best  results  has  been  extensively 
discussed  by  surgeons  and  physicians,  who  have  brought  forward  elaborate 
statistics  to  support  their  respective  lines  of  treatment  (vide  Tuberculous 
Peritonitis).  An  obvious  advantage  of  laparotomy  is  that  a  local  focus  of 
tuberculous  disease  which  may  give  rise  to  re-infection  and  relapse  after  partial 
or  apparent  cure  may  thus  be  detected  and  removed.  Out  of  W.  Mayo's*  26 
cases  in  which  tuberculous  Fallopian  tubes  were  removed,  25  recovered 
permanently,  and  in  7  of  these  simple  laparotomy  had  previously  been 
performed  from  one  to  four  times  for  the  cure  of  tuberculous  peritonitis. 
The  operative  treatment  of  the  ascites  of  portal  cirrhosis  is  referred  to 
elsewhere  {see  Liver,  Cirrhosis  of). 

Paracentesis  can  hardly  be  regarded  as  a  form  of  treatment  which  directly 
influences  the  prognosis  of  ascites  ;  it  is  a  necessary  means  of  obtaining  relief 
from  mechanical  obstruction  rather  than  a  curative  measure.  The  risk  of 
peritoneal  infection  or  haemorrhage  (from  wounds  of  the  deep  epigastric  or  other 
vessels),  or  of  direct  damage  to  the  abdominal  viscera  from  the  insertion  of  a 
trocar  and  cannula,  is  almost  negligible.  Repeated  paracentesis,  however,  may 
set  up  some  chronic  peritonitis,  and  so  perpetuate  ascites  originally  due  to  some 
other  lesion,  such  as  the  backward  pressure  of  heart  disease.  In  hepatic  cirrhosis, 
death  from  coma  sometimes  follows  soon  after  tapping,  but  this  is  because  the 
ascites  is  a  terminal  event,  and  is  not  a  result  of  the  paracentesis. 

Frequency  of  Tappings. — On  the  whole,  frequent  tappings  are  rather  favour- 
able than  otherwise,  as  they  show  that  the  condition  is  chronic  and  may  thus 
exclude  malignant  disease.  In  chronic  simple  peritonitis  in  which  ascitic  life 
is  longer  than  in  other  conditions,  repeated  paracentesis  may  be  necessary  ;  an 
extreme  instance  of  this  is  Rumpf's  patient,  who  was  tapped  301  times  in  sixteen 
years.  Another  remarkable  example  of  ascitic  life  was  that  of  a  woman  who 
was  tapped  299  times  in  nine  years,  sometimes  twice  a  week,  the  causal  disease 
being  papillomatous  disease  of  the  ovaries  (Pye-Smith^).  While  rapid 
re-accumulation  is  not  necessarily  of  evil  omen,  its  occurrence  in  cirrhosis  at 
such  a  rate  as  to  require  a  fresh  tapping  after  two  or  three  days'  interval, 
especially  if  accompanied  by  haematemesis  and  metena,  may  be  due  to  throm- 
bosis of  the  portal  vein,  which  is  extremely  likely  to  precipitate  a  fatal  issue. 
Ascites  may  be  a  terminal  event,  and  therefore  of  very  grave  significance.  Thus, 
in  uncomplicated  cirrhosis,  tapping  is  seldom  required  more  than  twice,  and  the 
prolongation    of    life    is    shorter    than    in    cirrhosis    complicated   with    chronic 


ASCITES  91 

peritonitis,  in  which  more  tappings  are  required,  and  in  chronic  peritonitis.  In 
some  "cases  of  fatal  cirrhosis,  ascites  does  not  require  tapping.  The  prognosis, 
however,  is  not  necessarily  bad  because  tapping  is  not  required,  for  in  tuberculous 
peritonitis  it  is  seldom  called  for,  and  in  syphilitic  disease  of  the  liver,  anti- 
syphilitic  treatment  may  be  followed  by  rapid  disappearance  of  the  fluid.  The 
introduction  into  the  peritoneal  cavity  at  the  end  of  paracentesis  of  a  dilute 
solution  of  adrenin  has  in  some  instances  prevented  or  delayed  re-accumulation, 
but  its  action  is  not  sufficiently  constant  to  be  relied  upon. 

In  Individual  Cases. — Age  bears  on  the  prognosis  in  so  far  that,  apart  from 
cardiac  disease,  ascites  in  children  is  nearly  always  due  to  tuberculous  peritonitis, 
in  which  the  outlook  is  fairly  good. 

The  association  of  jaundice  with  ascites  is  seen  in  malignant  disease  and  in 
cirrhosis,  and  is  therefore  a  bad  prognostic  ;  deep  jaundice  almost  certainly 
points  to  malignant  disease.  The  combination  of  ascites  and  oedema  of  the 
feet  may  precede  the  onset  of  ascites  in  cirrhosis,  and  is  then  a  bad  sign  ;  but 
in  the  backward  pressure  of  heart  disease  this  sequence  is  of  comparatively  little 
importance.  Extensive  ascites  may  induce  oedema  of  the  feet  mechanically, 
by  pressure  on  the  inferior  vena  cava,  and  in  rare  instances  gives  rise  to  a  pleural 
effusion  (Caboti),  and  these  results  may  disappear  if  the  ascites  is  cured.  The 
association  of  pleural  and  ascitic  effusions  should  not  necessarily  cause  more 
anxiety  than  the  presence  of  ascites  alone  ;  for  it  is  sometimes  seen  in  simple 
chronic  peritonitis ;  and  cases  of  tuberculous  peritonitis  thus  complicated  may 
do  well.  On  the  other  hand,  it  may  occur  in  cirrhosis,  usually  from  tuberculous 
pleurisy,  and  in  widespread  malignant  disease.  Fever  is  not  uncommon 
at  the  onset  of  tuberculous  peritonitis,  and  it  is  only  when  persistent 
that  it  causes  serious  anxiety  as  to  the  future  of  the  case.  In  cirrhosis 
the  onset  of  ascites  with  fever  points  to  a  rapid  course  or  to  some  compli- 
cation, such  as  tuberculous  infection,  especially  of  the  peritoneum.  In 
ascites  due  to  hepatic  syphilis,  any  associated  fever  is  easily  removed  by  efficient 
antisyphilitic  treatment.  Albuminuria  has  not  any  special  bearing  on  the 
prognosis  of  ascites  ;  for  the  ascites  of  chronic  renal  disease  may  clear  up  ; 
chronic  simple  peritonitis,  in  which  ascites  lasts  for  long  periods,  may  be  associated 
with  chronic  renal  disease  ;  syphilis  may  give  rise  to  both  ascites  and  albumin- 
uria ;  and  in  some  instances  albuminuria  may  be  directly  due  to  the  pressure  of 
the  ascitic  effusion  on  the  renal  veins.  The  presence  of  sugar  in  the  ascitic 
fluid  occurs  in  cases  of  cirrhosis  with  hemochromatosis,  in  which  glycosuria 
usually  supervenes  about  a  year  before  death,  and  so  is  a  bad  prognostic ; 
but  it  is  hardly  likely  to  be  noticed  before  glycosuria  has  been  detected.  The 
presence  of  melanin  in  the  urine,  which  is  easily  established  by  the  occurrence 
of  a  dark  colour,  either  after  the  addition  of  nitric  acid  or  of  ferric  chloride, 
proves  that  there  is  a  malignant  melanotic  growth,  almost  certainly  in  the 
liver. 

Physical  Characters  of  the  Ascitic  Fluid. — Clear  ascitic  fluid  is  met  with  both 
in  conditions,  such  as  hepatic  cirrhosis,  backward  pressure  from  cardiac  disease, 
and  occasionally  malignant  growth,  in  which  the  outlook  is  grave,  and  also  in 
tuberculous  peritonitis,  in  which  the  prognosis  is  comparatively  good.  In 
cirrhosis  there  is  often  a  yellow  tint  due  to  bile,  and  this  may  also  occur  in  cardiac 
disease,  so  that  this  coloration  is  somewhat  ominous.  Generally  speaking, 
without  the  assistance  of  a  cytological  examination  (vide  infra),  these  naked-eye 
appearances  do  not  justify  an  opinion  as  to  the  prognosis.  Turbid  ascitic  fluid 
points  to  subacute  inflammation,  and  is  also  seen  in  less  favourable  cases  of 
tuberculous  peritonitis.  In  milky  ascites  the  prognosis  is  grave  ;  out  of  173 
collected   cases    116,    or    67    per    cent,   proved    fatal,    the    mortality    for   the 


92  INDEX     OF     PROGNOSIS 

pseudo-chylous  cases  (70-4  per  cent)  being  higher  than  that  (66  per  cent)  of  the 
chylous  cases  (Wallis  and  Scholberg^). 

Blood-stained  ascites,  which  must  be  distinguished  from  an  effusion  of  blood 
(hsemo-peritoneum),  suggests  intra-abdominal  malignant  disease,  and  so  makes 
the  outlook  extremely  grave  ;  but  it  may  occur  in  portal  cirrhosis,  usually  as 
the  result  of  a  previous  tapping,  and  in  association  with  ovarian  cysts  and 
uterine  fibromyomas.  Out  of  31  cases  of  ascites  due  to  ovarian  cysts,  8  were 
blood-stained,  and  out  of  55  cases  of  ascites  due  to  uterine  fibromyomas,  10 
were  blood-stained  (Cabot).  In  these  cases,  the  ascites  can  be  permanently 
cured  by  removal  of  the  innocent  tumour.  A  blood-stained  ascites  therefore 
does  not  always  cause  grave  anxiety-.  A  mucinoid  ascites,  which  occurs  in  some 
cases  of  intra-abdominal  malignant  disease  and  also  in  association  vAt\\.  leaking 
ovarian  cysts,  renders  the  prognosis  anxious  but  not  certainly  hopeless. 

Prognosis  from  Cytological  Data. — A  predominance  of  endothelial  cells  occurs 
in  passive  effusions,  as  in  heart  disease  and  cirrhosis,  and,  since  ascites  due  to 
these  causes  is  a  late  event,  it  is  a  somewhat  grave  sign.  A  high  lymphocytosis 
usually  points  to  tuberculous  peritonitis,  in  which  the  outlook  is  comparatively 
favourable  ;  but  in  some  cases  of  portal  cirrhosis  in  which  there  is  no  evidence 
of  tuberculosis  in  the  abdominal  cavity  after  death,  lymphocytes  are  the  pre- 
dominating cells.  The  presence  of  multinuclear  cells  and  of  atj^ical  mitoses 
strongly  suggests  malignant  disease  of  the  peritoneum.  Fragments  of  villous 
growth  make  the  prognosis  good,  as  their  presence  shows  that  the  ascites  is 
probably  due  to  implantation  of  ovarian  papilloma  on  the  peritoneum  ;  for  if 
the  primary  tumour  is  removed,  the  secondary  implantations  and  the  ascites 
disappear.  If  the  opsonic  index  of  the  fluid  for  tubercle  bacilli  is  lower  than 
that  of  the  blood,  the  cause  is  tuberculous  peritonitis  and  the  outlook  fairly 
favourable,  provided  there  is  no  reason  to  believe  that  the  case  is  one  of 
cirrhosis  with  superadded  tuberculous  infection.  When  the  Wassermann 
reaction  is  better  marked  in  the  ascitic  fluid  than  in  the  blood  (Esmein  and 
Parvu ') ,  the  cause  is  syphilitic  disease,  and  therefore  likely  to  be  cured  by  specific 
treatment. 

References. — ^Cabot,  Amer.  Jour.  Med.  Sci.  Philad.  1912,  clxiii,  i  ;  ^Ramsbottom, 
Med.  Chron.  Manchester,  1906-7,  xlv,  7  ;  3:\iayo,  Jour.  Amer.  Med.  Assoc.  Chicago, 
1904,  xlix,  1157  ;  *Pye-Smith,  Trans.  Path.  Soc.  189s,  xliv,  iii  ;  ^Wallis  and  Scholberg, 
Quart.  Jour.  Med.  Oxford,  1910-11,  iv,  171  ;  ^Esmein  et  Parvu,  C.R.  Soc.  d.  Biol. 
Paris,  1909,  Ixvi,  159.  H.  D.  Rolleston. 

ASTHMA,  BRONCHIAL.. — This  disease  is  not  fatal  in  itself,  but  its  complica- 
tions may  shorten  life.  The  paroxysm  seldom  if  ever  causes  death,  although 
there  is  at  least  one  instance  on  record  in  which  artificial  respiration  was  re- 
quired. There  are  numerous  cases  of  asthmatics  having  reached  old  age,  but 
insurance  records  show  that  the  majority  do  not  live  out  their  expectation. 
As  a  general  rule,  it  may  be  stated  that  when  the  first  attack  takes  place  in  early 
childhood  there  is  a  fair  prospect  that  the  disorder  will  cease  when  puberty  is 
reached  ;  but  a  number  of  cases  have  occurred  in  which  asthma  first  developed 
at  the  age  of  four  or  five  and  continued  at  intervals  to  the  age  of  seventy 
or  over.  If  middle  age  is  not  passed  before  the  first  attack  occurs,  there  is 
alwaj's  hope  of  a  cure.  After  the  age  of  forty-five,  however,  the  tendency  is 
usually  towards  a  progressive  increase  in  the  severit}-  of  the  symptoms.  The 
disappearance  of  all  symptoms  does  not  necessarily  mean  a  permanent  cure, 
for  the  disorder  may  be  absent  for  many  years  and  then  reappear. 

In  estimating  the  prognosis  in  cases  of  asthma  in  which  marked  complications 
have  not  become  estabhshed,  the  most  important  factor  is  the  recognition  of 


ATAXIAS  93 

the  cause  in  the  particular  patient.  In  some  instances  the  paroxysms  can  be 
definitely  associated  with  particular  climates,  or  particular  odours,  or  forms  of 
dust.  For  example,  some  soldiers  cannot  be  present  when  a  horse  is  groomed, 
without  suffering  from  an  asthmatic  attack  ;  other  persons  have  a  paroxysm 
when  they  sleep  on  a  feather  bed.  When  the  exciting  cause  can  be  shown  to  be 
something  which  causes  stimulation  of  an  unduly  sensitive  nasal  mucous 
membrane,  the  attacks  can  frequently  be  stopped  altogether  by  appropriate 
treatment,  provided  that  the  patient  has  not  been  a  sufferer  for  long,  and  has 
not  acquired  a  '  habit.'  In  other  cases,  when  it  is  impossible  to  remove  the 
primary  cause,  treatment  such  as  light  cauterization  of  the  nerve  of  the  nasal 
septum  appears  to  diminish  the  sensitiveness  of  the  nasal  mucous  membrane, 
and  to  give  rehef  in  a  considerable  proportion  of  cases.  This  reUef  may  be 
dramatic  at  times,  but  it  would  appear  seldom  to  be  permanent,  although  it  may 
extend  over  several  years.  The  use  of  intranasal  remedies,  such  as  dilute 
preparations  of  cocaine,  often  give  relief  for  similar  reasons,  but  they  seldom 
if  ever  produce  a  permanent  cure.  At  one  time  it  was  thought  that  the  removal 
of  gross  abnormalities  in  the  nose  of  asthmatic  patients  would  be  attended  with 
excellent  results.  These  expectations  have  not  been  confirmed,  and  it  is  doubtful 
whether  success  is  obtained  in  more  than  five  per  cent  of  these  operations, 
whereas  in  a  not  inconsiderable  number  the  asthmatic  attacks  are  aggravated. 
Further,  it  is  a  curious  thing  that  if  a  polypus  is  removed  before  the  light 
cauterization  treatment,  the  symptoms  may  become  worse  ;  whereas  if  the 
cauterization  of  the  septal  nerve  precedes  the  removal  of  the  polypus,  good 
results  m.ay  be  obtained. 

As  a  further  argument  of  the  importance  of  ascertaining  the  cause  in  each 
case,  it  should  be  mentioned  that  if  the  disorder  appears  to  be  associated  definitely 
with  gout,  high  blood-pressure,  chronic  constipation,  or  other  pathological  con- 
dition, appropriate  treatment  directed  against  the  cause  may  do  much  to  lessen 
the  frequency  of  the  attacks,  although  it  seldom  produces  a  lasting  cure. 

In  all  well-established  cases,  we  have  to  take  the  question  of  the  family 
longevity  into  account  in  estimating  the  prognosis,  but  in  every  case  the  most 
important  factors  are  the  amount  of  emphysema,  the  degree  of  bronchial  catarrh, 
and  the  condition  of  the  right  heart.  These  complications  all  increase  the 
tendency  to  asthmatic  attacks,  which  in  turn  increase  the  severity  of  the 
complications,  and  so  the  patient  lives  in  a  vicious  circle.  By  the  relief  of 
complications  much  can  be  done  to  prolong  Life.  The  introduction  of  appropriate 
vaccine  treatment  for  bronchitis  has  helped  to  prolong  the  life  of  many 
asthmatics.  In  a  number  of  instances  considerable  relief  of  the  bronchial 
catarrh  has  been  obtained,  together  with  an  increased  immunity  against 
particular  organisms  ;  hence  longer  intervals  occur  between  the  attacks  of 
bronchitis,  and  consequently  there  is  greater  freedom  from  the  paroxysms. 
Again,  the  use  of  '  pressure  baths '  for  the  treatment  of  emphysema  has  given 
considerable  relief,  and  hence  a  longer  life  in  some  cases.  In  fact,  it  may  be 
stated  with  some  conviction  that  modern  methods  of  treatment  have  tended, 
by  the  removal  of  the  initial  cause,  or  by  the  relief  of  serious  complications,  to 
do  much  to  improve  the  general  prognosis  in  persons  suffering  from  asthma. 

It  may  be  of  interest  to  add,  that  a  person  who  suffers  from  asthma  seldom 
develops  tuberculosis,  cancer,  or  Bright's  disease.  Arthur  Latham. 

ATAXIAS. 

Tabetic  Ataxia. — As  we  have  indicated  elsewhere  {see  Tabes  Dorsalis),  ataxia 
is  a  relatively  late  symptom  of  tabes,  and  in  a  large  proportion  of  tabetic  cases, 
if  the  malady  be  recognized  in  the  early  stage,  ataxia  need  never  develop  at  all. 


94 


INDEX     OF     PROGNOSIS 


The  symptom  is  best  prevented  by  careful  avoidence  of  physical  over-exertion 
and  by  systematic  exercises  of  the  limbs,  always  stopping  short  of  any  sensation 
of  fatigue. 

Once  ataxia  has  supervened,  its  intensity  is  proportional  to  the  muscular 
hypotonia,  and  to  the  degree  of  impairment  of  joint-sense  and  of  kinaesthetic 
sense. 

The  prospects  of  alleviation  or  cure  of  tabetic  ataxia  vary  widely  in  different 
cases.  The  occurrence  of  optic  atrophy  seems  to  have  a  mitigating  effect  upon 
its  incidence  ;  this,  however,  only  applies  to  cases  of  moderate  ataxia  in  which 
optic  atrophy  supervenes  relatively  early  in  the  course  of  the  disease.  In  some 
tabetic  cases  where  ataxia  has  developed  with  great  rapidity,  rest  in  bed  for  a  few 
weeks  or  months  has  a  markedly  beneficial  effect ;  and  the  patient,  previously 
unable  to  walk  without  support,  may  spontaneously  regain  to  a  large  extent 
his  powers  of  progression.  In  other  cases  again,  where  the  ataxia  has  been 
slowly  and  steadily  getting  worse,  an  acute  intercurrent  illness,  confining  the 
patient  to  bed,  may  rapidly  aggravate  all  the  symptoms,  so  that  he  may  pass 
from  the  ataxic  to  the  so-called  paralytic  or  helpless  stage.  In  the  majority  of 
cases,  however,  the  ataxia  is  slowly  and  gradually  progressive.  What  is  the 
prospect  of  improvement  in  this  class  of  tabetic  patients  ?  Carefully  devised 
exercises,  under  skilled  supervision,  can  generally  improve  the  ataxic  symptoms, 
the  amount  of  such  improvement  being  dependent  on  the  intelligence  of  the 
patient  and  upon  the  patience  and  ingenuity  of  the  physician.  It  is  not 
uncommon  for  a  previously  bedridden  patient  thus  to  regain  the  power  of 
standing  or  even  walking,  with  or  without  support.  Or  a  patient  in  whom  the 
gait  is  moderately  ataxic  may,  as  a  result  of  these  exercises,  gain  confidence  to 
such  a  degree  that  he  succeeds  in  correcting  and  concealing  his  ataxia,  so  as  no 
longer  to  be  an  object  of  remark  to  the  unskilled  observer.  Real  cure  of  ataxia 
does  not  occur,  but  the  acquisition  of  new  modes  of  movement  has  a  compensatory 
effect  and  may  to  a  large  extent  conceal  the  old  ataxia. 

Family  and  Hereditary  Ataxia. — Whether  this  be  the  type  known  as  Friedreich's, 
Marie's  cerebellar  type,  or  the  intermediate  spino-cerebellar  variety,  the  ataxia 
has  a  slow  and  insidious  onset  in  childhood  and  adolescence,  the  legs  being 
affected  earlier  and  more  severely  than  the  arms.  The  degenerative  process 
being  essentially  progressive,  the  prognosis  is  unfavourable  as  regards  relief  of 
the  ataxia,  and  it  is  futile  to  attempt  re-educative  exercises.  The  malady  itself 
does  not  necessarily  shorten  life,  and  the  patient  may  survive  for  many  years, 
even  when  helplessly  ataxic.  The  prognosis  as  to  life  depends  upon  the  assiduity 
with  which  the  patient  is  nursed  and  looked  after,  and  upon  the  care  with  which 
intercurrent  maladies  can  be  avoided. 

Ataxia  due  to  Focal  Lesions  of  tlie  Cerebellum. — This  may  be  vascular  in  origin 
(as  in  thrombosis  or  haemorrhage),  or  inflammatory  (as  in  abscess,  acute  encephal- 
itis or  locaUzed  meningitis),  or  associated  with  cerebeUar  tumour.  In  such 
cases,  the  prognosis  of  the  ataxia  depends  on  whether  the  underlying  cerebellar 
disease  can  be  removed  by  surgical  or  medicinal  means.  If  so,  the  ataxia  may 
entirely  disappear,  even  in  cases  where  a  considerable  amount  of  cerebellar  tissue 
has  been  permanently  destroyed. 

Ataxia  due  to  Focal  Lesions  elsewhere  in  the  Brain. — In  cases  where  ataxia  is 
one  of  the  symptoms  of  focal  disease  in  other  parts  of  the  brain — e.g.,  in  the 
corpora  quadrigemina,  optic  thalamus,  crura  cerebri,  etc., — the  prognosis  is,  as  a 
rule,  unfavourable  ;  since,  even  if  the  lesion  happens  to  be  a  stationary  one, 
compensatory  action  by  other  parts  of  the  brain  does  not,  as  a  rule,  occur. 

Purves  Stewart. 

ATROPHY,  MUSCULAR [See  Muscular  Atrophies.) 


BLADDER,     CALCULUS     OF  95 

BERI-BERI. — The  prognosis  is  variable,  and  in  all  countries  the  mortality 
is  less  now  than  it  was  a  few  years  ago.  Thus,  in  the  Malay  States,  the  mortality 
in  the  institutions  used  to  be  from  10  to  15  per  cent,  but  in  later  years  was  only 
2  to  4  per  cent.  Both  higher  and  lower  rates  have  been  recorded,  and  in  some 
outbreaks  it  has  been  40  per  cent  or  more.  In  others,  where  all  the  cases  are  of 
a  mild  type,  it  may  be  under  2  per  cent.  The  larger  the  proportion  of  the  '  wet ' 
variet}',  the  higher  the  mortaUty.  Recovery,  when  it  takes  place,  is  usually 
complete  ;  but  the  restoration  of  the  deep  reflexes  may  be  delayed,  and  in  a 
small  proportion  of  cases  there  is  permanent  loss  of  power  of  the  extensor  muscles. 

C.  W.  Daniels 

BLACKWATER  FEVER. — This  disease  is  variable  in  severity.  Essentially 
an  acute  hemolytic  process  of  doubtful  causation,  it  may  last  for  an  hour  or  two, 
when  it  will  be  no  more  dangerous  than  a  paroxysm  of  paroxj-smal  haemoglobin- 
uria  ;  or  it  may  last  for  three  days  or  even  more,  when  four-fifths  of  the  blood 
in  the  vessels  may  be  destroyed,  and  death  occur  from  the  anaemia.  In  other 
cases  the  continued  fever,  or  sometimes  h^-perpyrexia,  may  cause  death  in 
this   anaemic   condition. 

The  cause  of  nearly  four-fifths  of  the  deaths  is  suppression  of  urine,  due  to 
blocking  of  the  renal  tubules  in  the  kidneys,  and  particularly  of  the  tubules  in 
the  pyramids.  This  process  commences  as  soon  as  the  urine  becomes  loaded 
with  hsemolytic  products,  and  the  prognosis  is  in  the  main  determined  by  the 
success  of  measures  adopted  from  the  onset  of  the  disease  and  designed  to 
prevent  this  occurrence.  The  risks  from  this  cause,  suppression,  in  cases 
treated  from  the  onset,  is  much  reduced,  and  in  such  cases  the  mortality  is 
under  10  per  cent. 

Where  the  tubules,  or  even  a  large  proportion  of  them,  become  blocked,  the 
outlook  is  most  unfavourable.  Usually  death  takes  place  within  three  days 
of  the  onset  of  suppression,  but  may  be  postponed  for  a  week,  or  even  more. 

In  some  cases  the  flow  of  urine  is  re-established  as  a  result  of  the  large  quantities 
of  fluid  given  in  various  ways.  If  the  urine  be  of  low  specific  gravity,  it  usually 
indicates  that  only  a  small  portion  of  the  kidney  has  resumed  its  functions,  and 
death  occurs.  Operation,  such  as  incision  of  the  kidneys,  may  result  in  a  flow 
of  such  urine,  but  these  cases  have  so  far  all  terminated  fatally. 

Under  modern  methods  of  treatment  the  mortahty,  including  all  cases,  even 
those  where  treatment  is  not  commenced  earlj',  is  about  30  per  cent. 

C.  W.  Dante  s 

BLADDER,  CALCULUS  OF. — Stone  in  the  bladder  is  a  painful  malady,  and 
it  is  seldom  that  the  disease  is  allowed  to  run  its  course  without  an  attempt 
at  relief  by  operation.  There  are,  however,  cases  where  the  symptoms  are 
comparatively  sUght,  so  that  the  patient  either  disregards  them,  or  knowing 
that  a  stone  is  present,  prefers  the  pain  or  discomfort  to  the  risk  of  operative 
interference.  Such  stones  may  remain  in  the  bladder  for  fifteen  or  twenty 
years,  or  even  longer,  and  reach  a  great  size.  Eventually,  however,  and  usually 
at  a  very  much  shorter  period  than  this,  an  unreUeved  vesical  calculus  causes 
death,  either  by  ascending  pyelonephritis,  or  by  back  pressure  causing  dilata- 
tion of  the  Iddney  and  interstitial  nephritis,  or  by  a  combination  of  the  two. 
In  the  great  majority  of  cases  an  operation  is  performed,  and  the  prognosis 
of  vesical  calculus  lies  in  the  success  or  failure  of  the  operative  measures  under- 
taken. 

The  following  factors  are  important  :  (i)  The  date  of  the  operation  ;  (2)  The 
presence  of  sepsis  ;  (3)  The  presence  of  bladder  complications  ;  (4)  The  presence 
of  kidney  complications  ;    (5)   The  result  of  the  operation. 


96  INDEX     OF     PROGNOSIS 

1.  The  Date  of  Operation. — When  a  small  calculus  is  lodged  in  the  bladder, 
its  removal  is  a  simple  matter,  and  the  danger  to  which  the  patient  is  exposed 
is  very  slight.  The  operation  can  be  performed  under  local  anaesthesia,  so 
that  the  small  danger  of  a  general  anaesthetic  is  avoided. 

An  evacuating  cannula  and  bulb  may  suffice  to  remove  the  calculus  from 
the  bladder,  or  the  use  of  a  small  lithotrite  may  be  necessary.  There  should  be 
no  mortality  for  such  an  operation. 

At  a  later  stage,  the  size,  number,  and  density  of  the  stones,  the  presence 
of  sepsis  and  of  other  complications,  render  the  outlook  for  operation  more 
serious.  In  the  advanced  stage,  when  the  kidneys  are  diseased,  operation  of 
whatever  kind  is  a  serious  undertaking,  and  is  attended  by  a  considerable 
mortality. 

2.  The  Presence  of  Sepsis. —  There  are  two  classes  of  cases.  In  one,  an  aseptic 
calculus  becomes  infected  either  spontaneously  or  after  the  passage  of  instru- 
ments ;    in  the  second,  the  calculus  develops  in  a  bladder  already  infected. 

The  majority  of  calculi  in  the  first  class  are  composed  mainly  of  oxalate  of 
lime  or  uric  acid,  and  they  increase  very  slowly  in  size  or  number.  When  the 
urine  becomes  infected,  and  especially  when  the  reaction  of  the  urine  becomes 
alkaline,  a  rapid  increase  in  size  takes  place  from  the  deposit  of  phosphates  on 
the  surface  of  the  stone.  Phosphatic  calculi  formed  in  an  infected  bladder 
develop  very  rapidly,  a  calculus  of  considerable  size  developing  in  a  few  weeks. 

Sepsis  affects  the  prognosis  in  two  ways.  The  mortality  of  operations  on 
infected  stones  greatly  exceeds  that  of  operations  on  aseptic  stones ;  and 
secondly,  the  probability  of  recurrence  after  operation  is  much  greater. 

3.  Bladder  Complications. — A  healthy  bladder,  or  one  with  a  moderate  degree 
of  cystitis,  will  permit  of  an  easily  performed  and  complete  litholapaxy,  the 
mortality  of  which  is  very  low,  and  the  probability  of  recurrence  slight.  When 
severe  cystitis  is  present,  and  the  bladder  is  acutely  spasmodic,  litholapaxy 
becomes  difficult  and  may  be  impossible,  and  lithotomy  becomes  necessary, 
with  a  higher  mortality. 

When  the  bladder  is  sacculated,  or  when  a  diverticulum  is  present,  litholapaxy 
should  not  be  performed,  and  suprapubic  lithotomy  is  necessary.  In  such 
cases  sepsis  is  always  present,  and  it  is  very  difficult  and  frequently  impossible, 
to  get  rid  of  the  infection.  The  prognosis  is  grave,  for  recurrence  of  the  stone 
is  probable,  and  ascending  pyelonephritis  may  supervene.  When  a  solitary 
diverticulum  of  large  size  is  present,  an  operation  for  the  removal  of  this  will 
be  necessary. 

New  growths  of  the  bladder  occasionally  complicate  calculus.     In  such  cases  . 
the  prognosis  depends  upon  the  nature  of  the  growth,  and  upon  the  ability  of 
the  surgeon  to  diagnose  its  presence  before  attempting  litholapaxy. 

Bilharzial  disease  of  the  bladder  is  a  grave  complication  of  stone,  met  with 
in  countries  where  bilharziosis  is  rife.  Septic  complications  are  common,  and 
fistulae  follow  cutting  operations  with  great  frequency.  Perineal  lithotomy 
is  the  operation  usually  chosen  by  those  experienced  in  such  cases. 

Enlargement  of  the  prostate  complicates  vesical  calculus  by  increasing  the 
probability  of  renal  complications,  and  if  the  obstruction  is  left  untreated,  by 
favouring  recurrence  of  the  stone.  Litholapaxy  is  possible  when  there  is  a 
moderate  enlargement  of  the  prostate  ;  but  it  is  unsafe,  and  may  be  mechanic- 
ally impossible,  when  the  enlargement  is  pronounced.  The  proper  treatment 
of  stone  in  the  bladder  with  enlarged  prostate  is  suprapubic  prostatectomy  with 
removal  of  the  calculus. 

4.  Kidney  Complications. —  Infection  of  the  kidneys  is  the  most  serious  compli- 
cation of  vesical  calculus,  and  is  the  commonest  cause  of  death  after  operation, 


BLADDER,     CALCULUS    OF 


97 


or  when  no  operation  has  been  performed.  The  infection  takes  the  form  of  a 
pyehtis  in  milder  cases,  and  a  pyelonephritis  in  the  more  severe. 

Stone  in  the  kidney  is  a  not  infrequent  complication.  In  many  of  these 
cases  the  stone  in  the  bladder  has  developed  on  a  small  calculus  passed  from 
the  kidney.  In  other  cases  the  bladder  is  the  seat  of  chronic  cystitis  from 
repeated  descending  infection  from  the  kidney,  and  the  vesical  calculus  forms 
in  the  infected  bladder.  Kidney  symptoms  may  be  absent  or  insignificant, 
and  the  presence  of  renal  calculi  and  infection  is  very  frequently  overlooked. 
The  prognosis  in  such  cases  is  grave.  An  operation  upon  the  kidney  is  required, 
in  addition  to  that  on  the  bladder,  and  nephrectomy  may  be  necessary. 

In  such  a  case  the  presence  of  cystitis,  if  this  cannot  be  cured,  is  a  menace  to 
the  remaining  kidney,   from  ascending  infection. 

5.  The  Results  of  Operation. — The  operation  chosen,  and  the  results  of 
operation,  depend  upon  the  factors  which  have  already  been  discussed  above. 
Litbolapaxy  is  the  operation  of  choice.  Suprapubic  lithotomy  is  performed 
when  there  are  bladder  complications,  such  as  sacculation,  diverticula,  bladder 
spasm,  enlargement  of  the  prostate,  intractable  cystitis,  new  growth  of  the 
bladder  ;  when  the  size  and  hardness  of  the  stone  make  crushing  impossible  ; 
or  when  septic  renal  complications  render  bladder  drainage  advisable. 

Perineal  lithotomy  is  reserved  for  special  cases,  such  as  those  with  stone  in 
the  urethra  complicating  vesical  calculus,  and  also  for  cases  of  bilharziosis. 

The  mortality  statistics  of  litholapaxy  are  much  lower  than  those  of  lithotomy, 
but  they  hardly  give  a  fair  index  of  the  relative  gravity  of  the  two  operations  ; 
for  many  surgeons  reserve  lithotomy  for  the  more  serious  complicated  cases, 
while  performing  litholapaxy  in  all  simple  ones.  The  following  figures  show 
the  results  of  1890  stone  operations  performed  at  St.  Peter's  Hospital  from 
1864  to  1914. 


Results  of  Operation  for  Stone  in  the  Bladder. 
{St.  Peter's  Hospital,    1 864-1 91 4.) 


Date 

Operations 

Cured  or 
lielieved 

Died 

Mortality 
per  cent 

18G4-73 

118 

100 

18 

15-25 

1874-83 

196 

166 

30 

15-30 

1884-93 

362 

332 

30 

8-29 

1894-03 

600 

571 

29 

4-80 

1904—13 

578 

559 

19 

3-28 

1914 

36 

35 

1 

2-85 

Statistics  collected  by  Keegan  of  stone  operations  in  India  show  that  the 
mortality  in  10,073  litholapaxies  was  3-96  per  cent  ;  in  7,201  cases  of  lateral 
lithotomy  it  was  11-02  per  cent,  and  in  147  cases  of  suprapubic  lithotomy, 
42-17  per  cent.  In  the  Indore  Charitable  Hospital,  Central  India,  in  the  period 
1 881  to  1900,  there  were  500  litholapaxies  in  boys,  with  11  deaths,  a  mortality 
of  2-2  per  cent  ;    and  18  litholapaxies  in  young  girls,  all  successful. 

The  death-rate  of  litholapaxy  in  the  hands  of  various  surgeons  is  as  follows  : 
Guyon,  2-7  per  cent ;  Zuckerkandl,  3-6  per  cent  ;  v.  Frisch,  2-6  per  cent  ; 
Legueu,  2  per  cent ;  Freyer,  2-61  per  cent.  Watson  collected  from  the  litera- 
ture 17,736  cases  of  litholapaxy,  with  426  deaths,  a  mortality  of  2-4  per  cent. 
The  influence  of  age  upon  the  result  was  shown  by  the  following  figures  : 
Between  one  and  fifteen  years  there  were  2518  cases,  with  a  mortality  of  1-7  per 

7 


98  INDEX     OF     PROGNOSIS 


cent;   between  sixteen  and  fifty,  719  cases,  with  a  mortality  of  i-6  per  cent; 
over  fifty  there  were  3395  cases,  with  a  mortality  of  4-4  per  cent. 

The  ■mortality  of  suprapubic  lithotomy  is  much  higher:  Zuckerkandl,  13-5  per 
cent;  v.  Frisch,  12-7  per  cent;  Barling,  17-8  per  cent;  Dittel,  15-6  per  cent; 
Preindelsberger,  12-9  per  cent ;  Guyon,  24-3  per  cent ;  Nicolich,  7-45  per  cent ; 
Freyer,  12-75  per  cent.  Watson  collected  3303  cases,  with  436  deaths  (13-2 
per  cent). 

The  high  mortality  of  suprapubic  lithotomy,  compared  with  litholapaxy, 
is  due  to  the  fact  that  all  the  grave  cases  were  treated  by  lithotomy.  When 
the  same  class  of  cases  is  treated  by  one  or  other  operation,  the  results  are 
less  disproportionate.  Thus  Assenfeldt,  in  460  cases  of  suprapubic  lithotomy, 
found  a  death-rate  of  3-6  per  cent. 

Late  Results  of  Operation. — Watson  found  19  per  cent  of  recurrence  in  902 
cases  of  litholapaxy,  and  in  more  than  two-thirds  of  these  the  patients  were 
fifty  years  of  age  or  over.  Zuckerkandl  found  12  per  cent  of  operated  cases 
recurred.  There  is  no  difference  in  recurrence  after  the  operation  between 
lithotomy  and  litholapaxy,  in  the  hands  of  an  experienced  surgeon.  The  use 
of  the  cystoscope  immediately  after  the  operation,  or  a  few  days  later,  checks 
the  result,  and  provides  against  allowing  the  patient  to  depart  with  fragments 
unre  moved. 

Recurrence  takes  place  most  frequently  from  new  formations  of  phosphatic 
stone,  usually  in  the  subjects  of  enlarged  prostate.  Recurrence  of  oxalate  of 
lime  or  of  uric  acid  calculi  is  much  less  frequent,  but  may  occur  from  the 
descent  of  calcuU  from  the  kidney,  or  from  new  formation  in  the  bladder.  The 
latter  is  very  rarely  the  result  of  fragments  left  behind  at  a  crushing  or  cutting 
operation.  The  recurrent  calculus,  after  removal  of  a  uric  acid  or  oxalate  of 
lime  calculus,  may  be  phosphatic,  and  is  due  to  changes  in  the  urine. 

The  effect  of  removal  of  an  enlarged  prostate  upon  the  recurrence  of  calculi 
varies  according  to  their  composition  and  the  state  of  the  urine.  Uric  acid 
and  oxalate  of  lime  calculi  rarely  recur  ;    phosphatic  calculi  frequently. 

/.  W.  Thomson  Walker. 

BLADDER,  EXSTROPHY  OF. — There  is  some  variation  in  the  degree  of 
extroversion  of  the  bladder.  In  the  common  form  the  anterior  wall  of  the 
bladder  is  deficient,  so  that  the  bladder  mucous  membrane  is  exposed  and 
bulges  above  the  rudimentary  penis,  and  the  urine  is  discharged  on  the  surface 
from  the  uncovered  ureteral  orifices.  The  conditions  of  existence  are  miserable 
in  the  extreme.  There  is  continual  escape  of  urine,  saturating  the  clothes, 
and  leading  to  inflammation  and  excoriation  of  the  skin  of  the  thighs  and 
buttocks.  The  child  lives  in  a  pungent  atmosphere  arising  from  decomposing 
urine,  and  his  life  is  a  burden  to  himself  and  to  those  around  him.  Associated 
deformities  such  as  hare-lip,  cleft  palate,  and  spina  bifida  may  be  present,  and 
contribute  to  a  fatal  issue  in  infancy  or  early  childhood. 

Progressive  dilatation  of  the  ureters  and  kidneys  occurs.  Ascending  pyelo- 
nephritis is  the  commonest  complication,  and  is  the  usual  cause  of  death — 
■which  takes  place,  as  a  rule,  during  childhood  or  youth.  Occasionally  the 
patients  survive  till  adult  life,  and  even  attain  old  age.  A  malignant  growth 
jmay  develop  in  the  exposed  bladder. 

The  operations  performed  for  extroversion  of  the  bladder  are  numerous, 
and  their  number  is  an  index  of  the  poor  results  generally  obtained.  The 
principal  symptoms  against  which  treatment  is  directed  are  the  incontinence 
of  urine,  the  pain  and  discomfort,  and  the  infection  ;  and  by  the  success  in 
abolishing  these  the  value  of  the  different  operations  may  be  measured.  These 
operations  will  be  considered  in  three  groups,  as  follows  : — 


BLADDER,     EXSTROPHY     OF  99 


1.  Autoplastic  Repair  of  the  Bladder. — The  ingenuity  of  many  surgeons, 
among  whom  are  Roux,  Sedillot,  Billroth,  Thiersch,  Wood,  Le  Fort,  and 
Legard,  has  been  devoted  to  closing  the  bladder  by  flaps  of  skin  ;  and  Pozzi, 
in  addition,  attempted  to  form  a  fibro- muscular  shield  in  front  of  the  recon- 
structed bladder,  from  the  adjacent  abdominal  wall. 

The  mortality  of  these  procedures  is  not  great,  but  the  results  are  not  satis- 
factory. There  is  frequently  failure  to  obtain  healing  in  even  the  most  carefully 
planned  operation,  and  many  secondary  operations  are  required.  Occasionally 
the  bladder  is  covered  in  at  a  single  operation.  The  total  gain  in  a  successful 
operation  of  this  nature  is  that  the  bladder  mucous  membrane  is  protected. 
The  incontinence  of  urine  continues,  but  the  patient  is  enabled  to  wear  a 
urinal,  and  thus  some  part  of  the  misery  is  relieved.  The  infection,  however, 
continues  unabated,  and  a  stone  not  infrequently  develops  in  the  partly  recon- 
structed bladder. 

2.  Suture  of  the  Margins  of  the  Bladder,  with  or  without  Previous  Operation 
on  the  Pelvic  Girdle. —  A  few  surgeons  (Gerdy,  Billroth)  have  endeavoured  to 
close  the  gap  by  dissecting  and  suturing  the  edges  of  the  bladder  wall.  This 
operation  has,  however,  been  attended  by  no  success. 

In  order  to  allow  of  the  approach  of  the  separated  pubic  bones,  as  a 
preliminary  to  closure  of  the  bladder,  Trendelenburg  performed  arthrotomy 
of  the  sacro-iliac  articulations.  The  posterior  ligaments  of  one  synchondrosis 
are  cut,  and  if  this  does  not  suffice  to  allow  the  pubic  bones  to  come  in  contact, 
the  other  side  is  similarly  treated,  and  the  patient  is  suspended  in  a  special 
apparatus  for  three  or  four  months,  when  an  attempt  is  made  to  close  the 
bladder.  The  operation  is  a  more  serious  one  than  any  of  the  preceding,  and 
the  wings  of  the  pelvis  have  been  known  to  become  separated  again  after  some 
time.  On  the  other  hand,  some  successes  have  been  obtained,  and  in  three 
cases  it  has  been  claimed  that  the  patient  was  continent  after  the  operation. 

Estor  states  that  continence  has  been  obtained  in  13  per  cent  of  the  cases 
operated  upon  by  this  method.  Short  of  this  the  mucous  membrane  of  the 
bladder  is  protected,  with  resulting  improvement  in  the  pain  and  inflammation. 

3.  Deviation  of  the  Course  of  the  Urine. — The  number  of  operations  of  this 
nature  is  so  great  that  only  a  few  of  the  most  successful  can  be  discussed. 

a.  Peter's  Operation. — Catheters  are  placed  in  the  ureters,  which  are  dissected 
out,  leaving  a  small  ring  of  the  vesical  mucous  membrane  attached  to  each. 
The  bladder  is  excised,  and  the  rectum  exposed  extraperitoneally.  The  ureters 
are  passed  through  the  rectal  wall,  and  the  catheters  are  drawn  through  the 
anus,  without  suture.  The  catheters  are  left  in  position  for  several  days.  A 
disadvantage  of  this  operation  is  that  the  sphincter  action  of  the  lower  ureters 
is  destroyed.  In  4  cases,  Peters  obtained  2  good  results,  i  failure,  and  i  death 
from  pyelonephritis.  Sherman  collected  11  cases  operated  by  this  method  ; 
of  these,  only  2  died  of  pyelonephritis. 

b.  Maydl's  Operation. — The  bladder  is  excised,  leaving  an  area  at  the  base 
which  includes  both  ureteric  orifices.  The  sigmoid  colon  is  exposed,  and  the 
bladder  base,  bearing  the  ureteric  orifices,  implanted  into  this.  Some  surgeons 
have  modified  this  by  implantation  into  the  rectum. 

The  immediate  mortality  of  Maydl's  operation  varies  from  5-5  per  cent 
(Josseraud,  18  cases)  to  26-7  per  cent  (Katz,  57  cases).  In  Petersen's  collection, 
31  patients  recovered  from  the  operation  :  2  of  these  died  of  pyelitis  within  a 
year  ;  while  in  6  cases  the  operation  was  followed  by  fistula,  which  subsequently 
closed  in  every  instance. 

Surgeons  are  by  no  means  unanimous  in  regard  to  the  protective  power  of 
the  ureteric  orifices,   thus  implanted,   against  ascending  infection.     In  experi- 


INDEX     OF     PROGNOSIS 


mental  work  on  dogs,  the  mortality  due  to  ascending  pj^elonephritis  is  very 
liigh.  Clinically,  some  surgeons  have  recorded  a  high  percentage  of  fatal  cases 
from  this  cause.  Pauchet,  out  of  4  cases,  had  3  deaths  from  ascending  infection, 
occurring  after  twelve,  fourteen,  and  fifteen  months  respectively.  On  the 
other  hand,  cases  have  been  recorded  where  the  patients  were  in  good  health 
some  years  after  the  operation.  Thus,  Resigotte  records  a  case  alive  and  well 
after  three  years,  Frank  i  after  four  years,  Maydl  2  after  four  and  iive  years, 
Graubner  and  von  Eiselsberg  each  i  after  five  years,  Ewald  i  after  nine  years, 
Estor  I  after  seven  years,  Tuf&er  i  after  seven  years,  Forgue  i  after  eight  years, 
Wolfler  I  after  ten  years,  and  Roux  2  after  three  and  ten  years  respectively. 

The  presence  of  urine  in  the  rectum  does  not  appear  to  have  caused  any 
reaction,  and  inflammation  of  the  mucous  membrane  is  very  rare. 

After  the  operation  continence  is  the  rule.  This  may  be  established  at  once, 
or  gradually  develop.  The  rectum  becomes  dilated,  and  a  considerable  quantity 
of  urine,  which  may  be  quite  clear,  is  discharged  voluntarily.  Occasionally, 
for  want  of  development  of  the  perineal  and  anal  muscles,  continence  is  not 
established.  This  occurred  in  one  case  in  Petersen's  collection.  The  condition 
of  the  rectal  sphincters  should  be  carefully  examined  before  embarking  upon 
the  operation. 

Maydl's  operation  is  the  most  successful  of  any  of  those  performed  for  extro- 
version of  the  bladder,  and  is  the  only  one  in  which  a  considerable  proportion 
of  cases  shows  continence,  together  with  disappearance  of  the  pain  and  dis- 
comfort, and  an  absence  of  ascending  infection. 

c.  Soiibottine's  Operation. — A  rectovesical  fistula  is  created,  the  rectum  is 
opened  along  its  posterior  wall  after  removing  the  coccyx,  and  a  broad  vertical 
band  of  rectal  wall,  including  the  fistula,  is  raised  on  the  anterior  rectal  wall, 
and  the  edges  united  so  that  a  tube  is  formed,  the  orifice  of  which  is  within  the 
anal  sphincter.     The  gap  in  the  anterior  bladder  wall  is  then  closed. 

Of  this  operation  Estor  says  that  it  is  as  efficient  in  obtaining  continence  as 
that  of  Maydl,  and  has  the  advantage  of  separating  the  urine  from  contact 
with  fagcal  matter.  At  the  same  time  the  operation  is  very  complicated  and 
may  fail  at  some  part.  The  infected  bladder  is  retained,  and  may  be  a  source 
of  trouble  from  calculus  or  other  cause.  Further,  damage  is  done  to  the  anal 
sphincters,  already''  weak  in  many  cases.  In  creating  the  retrovesical  fistula, 
the  peritoneum  may  be  opened  and  infected.  Three  cases  operated  on  by 
Soubottine  died  of  peritonitis.  In  the  first  6  cases  where  the  whole  operation 
was  performed  at  one  sitting,  2  died  ;  whereas,  in  10  cases  in  which  a  more 
recent  operation  in  successive  stages  has  been  employed,  all  survived.  The 
functional  result  has  been  very  satisfactory  in  these  10  cases  ;  in  all  there  has 
been  voluntary  micturition  five  or  six  times  in  twenty-four  hours,  the  urine 
has  remained  clear,  and  ascending  infection  has  not  incurred. 

/.   W.  Thomson    Walker. 

BLADDER,  GROWTHS  OF. — For  the  purpose  of  prognosis,  growths  of  the 
bladder  may  be  divided  into  two  groups  :  (i)  Papillomata  or  villous  growths  ; 
(2)  Malignant  growths.  It  is  true  that  there  are  tumours  which  possess  the 
characters  of  both  of  these  groups,  and  it  is  admitted  that  papilloma  of  the 
bladder  displays  features  that  differ  from  simple  growths  elsewhere.  The 
grouping  is,  nevertheless,  a  practical  one,  and  will  be  used,  while  recognizing 
the  pathological  fallacies  which  underlie  it. 

A  number  of  varieties  of  growths,  such  as  myoma,  fibroma,  and  myxoma, 
are  found,  but  so  rarely  that  they  do  not  merit  special  discussion. 

I.  Papilloma. — Papillomata  are  generally  regarded  as  benign  growths.  In 
the  bladder,  however,  they  show  certain  characters  which  give  them  a  place 


BLADDER,     GROWTHS     OF 


somewhere  between  the  well-defined  benign  and  the  clearly  recognized  malignant 
growths.  They  have  a  very  pronounced  tendency  to  become  multiple  ;  the 
distribution  of  smaller  papillomata  around  large  growths,  or  of  papillomata 
occurring  at  opposing  points  of  contact  of  the  bladder  wall,  suggest  a  special 
tendency  to  implantation  ;  there  is  also  a  very  pronounced  tendency  to  recur- 
rence of  the  tumours.  A  certain  number  of  papillomatous  growths,  after 
retaining  their  benign  characters  for  many  years,  infiltrate  the  submucous 
and  muscular  layers  of  the  bladder  wall,  and  show  signs  of  true  malignancy. 

In  view  of  these  facts,  some  authorities,  such  as  Albarran  and  Imbert,  and 
Brongersma,  regard  all  papillomata  of  the  bladder  as  malignant.  The  present 
writer  looks  upon  these  growths  as  pre-cancerous,  and  as  occupying  a  position 
in  regard  to  malignancy  somewhat  similar  to  that  of  leucoplakia  of  the  tongue. 

The  following  are  important  points  on  which  to  base  an  estimate  of  the 
prognosis  in  a  case  of  papilloma  of  the  bladder. 

a.  The  Duration  and  Complications. — The  history  of  a  case  of  papilloma  may 
extend  over  many  years,  an  operation  then  having  been  performed.  A  duration 
of  ten  or  fifteen  years  has  frequently  been  recorded,  and  Albarran  collected 
cases  with  a  history  of  symptoms  lasting  twelve,  fourteen,  and  thirty  years. 

Certain  complications  may  lead  to  a  fatal  result,  and  therefore  increase  the 
gravity  of  the  prognosis. 

Excessive  haemorrhage  occurs  in  some  papillomata.  As  a  rule,  the  attacks 
of  hsematuria  are  at  first  separated  by  long  intervals  (six  months,  or  even  one 
or  several  years),  but  gradually  the  intervals  become  shorter,  and  the  attacks 
more  prolonged  and  more  severe.  Profound  anaemia  may  ensue,  and  indirectly 
lead  to  a  fatal  result.  A  serious  complication  of  severe  haemorrhage  is  the 
formation  of  masses  of  clot  in  the  bladder.  Retention  of  urine  results  from 
the  inability  of  the  bladder  to  expel  the  clots.  The  danger  of  infecting  this 
clot-filled  bladder  by  passing  a  catheter  is  extreme  ;  and  if  infection  take  place, 
severe  cystitis  and  ascending  pyelonephritis  follow,  and  a  fatal  result  is  certain. 

Obstruction  of  the  outlet  of  the  bladder  occurs  when  masses  of  papillomata 
are  clustered  round  the  internal  meatus,  or  when  a  single  papilloma  with  a 
long  pedicle  acts  as  a  ball-valve.  In  such  cases  the  bladder  is  trabeculated 
and  sacculated,  and  the  ureters  and  pelves  of  the  kidneys  are  dilated.  Infection 
of  the  bladder  is  specially  liable  to  occur  in  such  cases,  and  death  from  uraemia 
is  a  common  result  of  injudicious  instrumentation,  or  of  radical  operation. 

Infection  of  the  bladder  in  papilloma  rarely  takes  place  spontaneously,  and 
in  this,  papilloma  differs  from  infiltrating  growths  of  the  bladder.  The  passage 
of  an  infected  catheter  or  cystoscope  is  the  usual  cause.  As  already  noted, 
it  is  specially  liable  to  occur  where  obstruction  is  a  feature  of  the  case. 

The  prognosis  in  a  case  of  infected  papillomatous  bladder  is  very  grave,  since 
the  infection  is  difficult  to  overcome  ;  and  ascending  pyelonephritis  is  a  frequent 
and  very  fatal  sequence. 

Exhaustion  accounts  for  a  large  proportion  of  deaths.  It  results  from  con- 
stant irritation  and  broken  rest,  from  septic  absorption,  and  from  frequently 
recurring    haemorrhage. 

b.  The  Results  of  Operation. — The  best  results  of  operation  are  obtained  in 
early  cases  where  the  growth  is  small,  single,  or  in  moderate  numbers,  the 
bladder  aseptic,  and  the  kidneys  healthy. 

In  order  to  operate  in  this  early  stage,  it  is  absolutely  necessary  that  those 
engaged  in  general  practice  should  thoroughly  grasp  the  grave  significance 
of  haematuria — the  cardinal  symptom  of  papilloma.  It  is  unfortunate  that 
the  haematuria  of  vesical  papilloma  is  unaccompanied  by  any  other  symptom, 
and  that  it  is  intermittent    in   character   with,    at    first,   prolonged   intervals 


INDEX     OF     PROGNOSIS 


between  the  attacks.  As  a  consequence,  the  patient,  and  not  uncommonly 
his  medical  attendant  also,  looks  upon  the  disappearance  of  the  haematuria 
as  indicating  the  cure  of  the  complaint. 

It  cannot  be  too  frequently  or  too  strongly  urged  that  an  attack  of  haematuria, 
however  transient,  is  a  matter  of  grave  significance,  and  that  the  source  of 
the  haematuria  must  be  traced  and  a  definite  diagnosis  made  ;  and  that  for 
this  purpose,  in  the  great  majority  of  cases,  the  cystoscope  is  necessary.  The 
absence  in  the  urine  of  cells  derived  from  the  surface  of  the  papilloma,  and  the 
absence  or  presence  of  cells  derived  from  the  kidneys  or  bladder,  are  insufficient 
data  on  which  to  base  a  diagnosis,  however  definite  the  clinical  pathologist's 
report  or  opinion  may  be. 

The  prognosis  for  recurrence  and  for  malignant  transformation  of  the  growth 
becomes  graver  as  the  duration  of  the  papilloma  is  more  prolonged. 

The  following  results  of  operation  on  the  papilloma  of  the  bladder  may  be 
noted  : — 

Endovesical  operations  by  means  of  the  operation  cystoscope  have  been 
used  by  some  surgeons.  Their  use  is  limited  to  the  most  favourable  types  of 
bladder  papilloma,  when  the  bladder  is  tolerant  of  intravesical  manipulation, 
and  the  papilloma  is  not  too  large  or  too  extensive.  Nitze  recorded  loi  intra- 
vesical operations  for  papilloma,  performed  before  1902  ;  of  these,  71  cases 
remained  without  recurrence,  there  were  18  recurrences,  and  12  cases  could 
not  be  followed. 

Removal  by  suprapubic  operation  includes  all  classes  of  case.  Rafin  collected 
265  cases,  of  which  21  died,  a  mortality  of  8  per  cent.  He  found,  however, 
that  the  mortality  improved  considerably  in  recent  cases  ;  thus,  in  the  latest 
156  cases,  the  death-rate  was  3-8  per  cent.  An  examination  by  this  author 
of  the  remote  results  in  115  cases,  showed  33  recurrences,  or  28  per  cent ;  there 
were  82  cases  without  recurrence,  at  periods  varying  from  one  to  five  years  ; 
in  18  cases  there  was  no  recurrence  after  a  period  of  over  three  years. 

Recurrences  of  papilloma  take  place  after  considerable  intervals,  such  as 
four,  six,  seven,  or  eight  years  after  operation.  According  to  Legueu,  the 
patient  can  never  consider  himself  completely  free  from  the  possibility  of 
recurrence. 

As  a  rule,  recurrence  after  operation  in  papilloma  takes  the  form  of  multiple 
growths,  at  first  of  small  size.  The  introduction  of  the  high-frequency  cauteri- 
zation of  papillomatous  growths,  by  Beer  of  New  York,  has  greatly  improved 
the  prognosis  in  such  cases.  The  bladder,  after  an  operation  for  papilloma, 
should  be  examined  at  intervals  of  three  months  at  first,  and  later,  of  six 
or  twelve  months,  and  on  the  first  appearance  of  recurrence,  the  small 
papillomatous  bud  is  destroyed  with  the  high-frequency  cautery.  Sufficient 
time  has  not  yet  elapsed  since  the  introduction  of  this  method  to  gauge  the 
full  effect  on  prognosis.  It  is  certain,  however,  that  by  this  means  the  number 
of  secondary  open  operations  will  be  considerably  diminished  ;  and,  the  treat- 
ment being  applied  in  the  earliest  stage  of  a  recurrence,  the  gravity  of  the 
procedure  will  be  much  less. 

A  certain  number  of  recurrent  growths,  after  operation  for  papilloma,  have 
proved  to  be  mahgnant.  Burckhardt  found  that  of  15  cases  operated  on  for 
papilloma,  and  in  which  the  growth  recurred,  the  recurrent  growth  was 
malignant  in  3. 

2.  Malignant  Growths. — The  outlook  in  malignant  growths  of  the  bladder, 
when  no  radical  operation  is  undertaken,  is  a  certainly  fatal  one.  The  duration 
of  the  disease  varies  considerably.  There  are  a  number  of  cases  where 
symptoms,  such  as  haematuria,  have  existed  for  some  years — as  long  as  five 


BLADDER,     GROWTHS     OF  103 

or  even  eight  years — and  then  a  rapid  advance  takes  place,  the  growth 
infiltrates  widely,  forming  metastases,  and  death  quickly  supervenes.  In  such 
cases  the  total  duration  of  symptoms,  up  to  the  time  of  death,  may  reach 
eight  to  ten  years.  The  most  common  type  shows  a  steady  advance  of  sym- 
ptoms, which  terminate  fatally   in   from   one   and   a   half   to   two   years. 

Malignant  growths  of  the  bladder  are,  in  their  earlier  stages,  admirably 
suited  for  radical  operation  in  proper  hands.  Spread  to  lymphatic  glands, 
and  metastatic  deposits  in  distant  parts,  take  place  only  in  the  latest  stage  ; 
and  the  prospect  of  cure  by  a  well-timed  and  properly  planned  operation  is, 
compared  with  malignant  growths  of  other  internal  organs,   extremely  good. 

The  following  factors  directly  influence  the  prognosis  by  their  effect  on  the 
result  of  operation. 

a.  The  Nature  of  the  Growth.— -The  different  varieties  of  malignant  growths 
of  the  bladder  vary  widely  in  their  rapidity  of  growth  and  tendency  to 
recurrence  after  operation.  The  most  chronic  in  its  growth,  and  the  slowest 
to  recur,  is  the  epitheliomatous  ulcer  or  cancroid,  which  forms  a  depressed 
ulcer,  and  has  the  structure  of  a  squamous  epithelioma.  The  nodular  malignant 
growth  varies  considerably  in  its  size,  and  also  in  the  rapidity  of  its  growth, 
and  recurrence  after  removal ;  histologically,  these  growths  show  either  the 
characters  of  a  spheroidal-celled  carcinoma,  or  they  are  formed  of  papillo- 
matous tissues  so  closely  welded  together  as  to  be  almost  unrecognizable.  Some 
malignant  papillomatous  tumours  show  rapid  and  luxuriant  growth,  and  very 
rapid  recurrence  after  operation. 

b.  The  Extent  of  the  Growth. — Extension  of  a  bladder  growth  may  be  intra- 
vesical, intramural,  perivesical,  or  there  may  be  glandular  involvement.  The 
intravesical  extension  is  gauged  by  means  of  the  cystoscope.  A  malignant 
growth  of  very  large  size  is  seldom  worth  while  operating  upon  with  the 
view  to  radical  cure,  as  it  will  certainly  have  passed  beyond  the  limits  of  the 
bladder  and  formed  deposits  elsewhere.  The  particular  size  of  the  growth  which 
experience  has  taught  me  is  suitable  for  partial  resection  of  the  bladder  does 
not  exceed  a  walnut  or  the  area  of  a  two-shilling  piece  as  seen  by  the  cystoscope. 
The  intramural  spread  is  almost  always  more  extensive  than  the  intravesical 
extent  would  suggest ;  it  is  best  gauged  by  the  finger,  after  opening  the 
bladder.  The  perivesical  spread  can  only  be  estimated  at  operation.  Extensive 
intramural  spread,  and  perivesical  encroachment  of  the  growth,  render  the 
case  unsuitable  for  partial  resection  of  the  bladder  wall,  and  therefore  affect 
adversely  the  prognosis. 

c.  The  Position  of  the  Growth. — A  growth  situated  at  or  near  the  apex  of  the 
bladder  is  in  the  ideal  position  for  resection.  As  the  position  of  the  growth, 
in  different  cases,  approaches  the  base,  it  becomes  less  and  less  suitable  for 
resection.  The  reason  for  this  is  not  due  to  any  increasing  malignancy  in 
growths  at  the  lower  part  of  the  bladder,  but  to  the  closer  relation  to  the 
ureters,  the  trigone,  prostate,  and  urethra. 

If  a  clear  exposure  of  the  lower  part  of  the  tumour  can  be  obtained,  and  the 
surgeon  does  not  allow  himself  to  be  hampered  by  an  attempt  to  avoid  the 
ureters  or  trigone,  the  middle  and  even  the  lower  parts  of  the  bladder  are  still 
suitable  for  resection  ;  the  lower  part  of  the  ureter  being,  if  necessary,  removed 
with  the  growth,  and  the  stump  implanted  in  the  bladder  wound. 

When  the  growth  has  encroached  upon  the  trigone,  or  lies  in  close  proximity 
to  the  urethral  orifice,  resection  should  not  be  performed.  In  3  out  of  5  of 
my  cases  of  recurrence  the  growth  was  situated  in  close  relation  to  the  trigone 
and  ureters,  and  in  2  of  these  the  size  was  so  considerable  as  to  interfere  with 
the  manipulation  at  the  lower  part  of  the  incision. 


I04 


INDEX     OF     PROGNOSIS 


d.  The  Condition  of  the  Bladder  and  Kidneys. — The  greatest  danger  at  the 
time  of  the  operation,  and  after  recovery  from  it,  is  sepsis.  Mahgnant 
growths  of  the  bladder  have  a  special  tendency  to  spontaneous  infection. 
Over  40  per  cent  of  all  the  cases  that  have  come  under  my  observation  have 
presented  the  clinical  picture  of  spontaneous  cystitis,  and  were  referred  to 
me  without  a  suspicion  that  a  malignant  growth  underlay  the  cystitis.  In 
2  per  cent  of  the  cases  the  cystitis  was  so  severe  and  persistent  that  opera- 
tion had  to  be  refused  on  that  account. 

Cystitis  is  not  only  a  danger  to  the  patient,  from  the  pelvic  cellulitis  and 
other  septic  complications  that  may  follow  operation,  but  it  gravely  hampers 
the  work  of  the  surgeon,  rendering  the  bladder  cavity  much  smaller,  and  the 
bladder  wall  difficult  to  manipulate. 

Ascending  pyelonephritis  may  be  present  before  the  operation,  and  accounts 
for  some  part  of  the  operation  mortality.  It  is  a  serious  danger  during  the 
early  part  of  convalescence  when  the  case  is  already  septic,  and  may  cause 
death  many  months  or  some  years  after  recovery  from  the  operation.  It  is 
not  more  liable  to  occur  when  a  ureter  has  been  transplanted  :  in  10  of  the 
author's  cases,  resection  of  the  ureter  and  implantation  in  the  wound  was 
necessary ;    in  none  of  these  cases  did  pyelonephritis  develop. 

Results  of  Operation  for  Malignant  Growths. 

Palliative  Operations. — These  occasionally  become  necessary  in  order  to  treat 
symptoms.  Apart  from  the  relief  given  in  this  way,  no  permanent  benefit  is 
obtained.  The  patients  survive  from  three  to  nine  months,  or,  less  frequently, 
a  year. 

Removal  of  the  Tumour. — Removal  only,  without  any  attempt  to  remove 
the  tissues  round  the  tumour,  does  not  appear  to  prolong  life.  Rafin  collected 
57  cases,  with  8  deaths,  or  14  per  cent.  Of  the  49  survivals,  only  38  were 
followed.  The  most  part  were  dead,  or  suffering  from  recurrence,  within  a  year  ; 
4  were  dead  of  recurrence  in  one  and  a  half,  two  and  a  half,  or  nine  years  ;  6 
had  not  shown  recurrence  after  periods  of  one,  one  and  a  quarter,  two,  four, 
and  four  and  a  half  j^ears. 

Resection  of  the  Bladder  Wall. — 

i.  Operation-mortality . — Rafin  collected  96  cases,  of  which  21  died,  a  mortality 
of  21-8  per  cent.  Rovsing  collected  16  cases,  with  3  deaths,  a  mortality  of 
18-7  per  cent. 

The  following  personal  statistics  may  be  noted  :— 


Operator 

Cases 

Deaths 

Mortality 
per  cent 

Brongersma                 -           36 
Heresco      ...             4 
Zuckerkandl       -        -             8 
Thomson  Walker       -           30 

5 
1 
0 
3 

14 

25 

0 

10 

ii.  End-results. — In  96  cases  collected  by  Rafin,  75  survived  the  operation, 
but  in  only  52  was  the  late  result  known.  Of  these,  31  were  followed  till  recur- 
rence appeared,  or  death,  supervened  ;  this  occurred  in  six  months  in  13  cases, 
twelve  months  in  11  cases,  in  the  second  year  in  i  case,  after  three  years  in 
2  cases,  after  four  years  in  2  cases.  There  were  21  cases  without  recurrence. 
Of  these,  12  were  followed  for  less  than  two  years,  while  9  were  followed  two 
years  or  over  :  4  two  years,  i  three  years,  i  three  and  a  quarter  years,  i  four 
years,  i  five  years,  and  i  six  years. 


BLADDER,     TUBERCULOSIS     OF  105 

In  Rovsing's  collected  cases,  13  survived  operation.  Of  these,  4  cases  died 
of  recurrence  from  four  and  a  half  to  nineteen  months  after  operation,  and  i 
died  of  cerebral  tumour.  The  following  cases  are  known  to  have  survived  : 
2  one  year,  i  seventeen  months,  2  three  years,  i  six  years. 

Brongersma  gives  the  following  results  in  his  cases  :  9  cases  died  from  recur- 
rence or  metastases  under  two  years,  i  died  some  months  after  operation  from 
pneumonia,  2  were  still  under  treatment,  18  showed  neither  recurrence  nor 
metastases  at  periods  varying  from  some  months  to  seven  years. 

Kiimmel  reports  that  of  47  cases  of  bladder  resection  for  malignant  growth, 
10  are  well  after  six  and  a  half,  eight,  fifteen,  and  sixteen  years,  and  i  died  of 
recurrence  ten  years  after  the  operation. 

In  25  cases  of  resection  by  the  author  in  which  late  information  was  obtained, 
there  were  3  deaths  from  ascending  pyelonephritis,  and  6  recurrences,  one  of 
which  was  re-operated,  and  was  well  four  years  after  the  second  operation. 
In  17  cases  the  patients  were  alive  and  without  recurrence,  as  follows  :  six 
months  after  operation  in  6  cases  ;  twelve  months  in  3  ;  eighteen  months  in  6  ; 
two  years  in  i  ;    and  four  and  a  half  years  in  i.     (Statistics,  March,  191 1.) 

Total  Extirpation  of  the  Bladder  [Cystectomy). — Of  39  cases  collected  from 
the  literature,  death  occurred  after  the  operation  in  18,  a  mortality  of  46- 1  per 
cent.  Only  10  cases  could  be  traced,  and  in  only  2  of  these  was  the  period 
after  the  operation  longer  than  fifteen  months  ;  i  was  well  five  years  afterwards 
(Hogge),  and  i  sixteen  years  (Pawlik).  Later  statistics  give  an  even  higher 
mortality.  Verhoogen  and  de  Graeuwe  collected  59  cases  of  total  cystectomy, 
with  an  operation  mortality  of  52-7  per  cent.  Of  the  27  cases  that  survived 
the  operation,  6  died  in  the  first  year,  7  died  before  the  third  year,  and  only  2 
survived  more  than  three  years.  Cystectomy  must,  at  the  present  time,  be 
looked  upon  as  a  desperate  measure  which  holds  out  little,  if  any,  prospect 
of  a  cure.  /.  w.  Thomson  Walker. 

BLADDER,  INJURIES  OF. — {See  Abdominal  Injuries.) 

BLADDER,  TUBERCULOSIS  OF. — It  is  now  well  recognized  that  tuberculosis 
of  the  bladder  is  never,  or  only  in  the  very  rarest  cases,  primary,  and  that  it 
results  from  extension  of  tuberculous  infection  from  the  kidney  by  way  of  the 
ureter,  or  from  the  prostate  or  seminal  vesicles.  This  being  the  case,  the 
prognosis  depends  largely  upon  that  of  tuberculosis  of  the  kidney  or  genital 
organs  ;  and  to  these  the  reader  is  referred.  {See  Kidney,  Tuberculosis  of  ; 
Epididymitis,  Tuberculous.) 

There  are,  however,  some  points  that  may  suitably  be  discussed  here. 

I.  The  Course  of  Untreated  or  Unsuccessfully  Treated  Vesical  Tuberculosis. — 
The  course  of  tuberculous  cystitis  is  slowly  progressive,  with  periods  of  improve- 
ment and  periods  of  relapse,  dependent  partly  upon  changes  of  diet  and  climate. 
At  the  commencement  there  may  be  a  period  of  acute  cystitis  which  subsides, 
a  slight  subacute  cystitis  persisting.  More  frequently,  however,  the  onset  is 
insidious,  and  the  progress  very  gradual.  After  some  years,  the  continual 
calls  to  micturate  become  very  distressing,  and  the  patient  is  worn  out  from 
loss  of  sleep.  If  septic  complications  are  avoided,  death  takes  place  after 
some  years  from  renal  failure  due  to  bilateral  renal  tuberculosis.  More  often 
there  are  septic  complications,  caused,  almost  invariably,  by  infection  intro- 
duced by  septic  catheterization,  or  after  drainage  of  the  bladder  by  cystotomy. 
The  condition  of  the  patient,  when  this  occurs,  is  distressing.  There  is  constant 
desire  to  micturate,  unsatisfied  by  the  passage,  with  pain  and  scalding,  of  a 
few  drops  of  urine  every  ten  or  fifteen  ininutes.  The  frequency  and  irritation 
continue  day  and  night.     During  the  day  some  method  of  collection  of  the 


io6  INDEX     OF     PROGNOSIS 

urine  becomes  necessary,  owing  to  the  active  incontinence  which  develops, 
and  a  rubber  urinal  is  worn  ;  during  the  night  the  rest  is  broken  by  the  constant 
calls,  and  bed-wetting  is  frequent.  Secondary  phosphatic  calculi  form  in  the 
bladder,  and  add  to  the  pain  and  distress.  Eventually,  exhaustion  combined 
with  septic  absorption  bring  about  a  fatal  result,  or  ascending  septic  pyelo- 
nephritis may  cut  short  the  course  of  the  disease. 

2.  The  Origin  of  the  Tuberculous  Infection. — Where  tuberculous  cystitis  is 
secondary  to  renal  tuberculosis,  the  prognosis  varies  at  different  stages  of  the 
disease.  In  unilateral  renal  tuberculosis,  tuberculous  cystitis  affects  the 
prognosis  but  little.  Removal  of  the  tuberculous  kidney  is  followed  in  most 
cases  by  a  disappearance  of  the  vesical  infection,  and  the  result  is  hastened 
by  a  course  of  tuberculin.  It  is  a  peculiarity  of  tuberculous  cystitis,  however, 
that  even  when  the  tuberculous  infection  has  been  quite  cured,  some  increase 
in  the  frequency  of  micturition  remains.  Another  point  of  interest  in  regard 
to  these  cases  is  that  tuberculous  ulceration  of  the  bladder  may  be  present, 
demonstrated  by  the  cystoscope,  and  yet  the  urine  be  absolutely  clear  to  the 
naked  eye. 

In  the  later  stages  of  renal  tuberculosis,  tuberculous  cystitis  is  a  serious 
complication,  from  the  constant  irritation  and  loss  of  sleep  that  it  produces, 
and  especially  from  the  danger  of  sepsis  and  ascending  pyelonephritis. 

In  tuberculous  cystitis  secondary  to  tubercle  of  the  prostate  and  seminal 
vesicles,  the  prognosis  is  not  so  good  as  in  the  early  stage  of  renal  tubercle. 
The  results  of  treatment  of  the  disease  of  the  prostate  and  seminal  vesicles  by 
operation  are  not  satisfactory,  and  septic  complications  are  very  frequent. 
Some  cases  react  well  to  tuberculin,  but  in  many  the  improvement  is  only 
partial  and  temporary. 

3.  The  Results  of  Treatment. — Removal  of  the  source  of  the  tuberculous 
infection,  as  for  instance  the  kidney,  is  the  basis  of  treatment.  Where  this  is 
impossible,  as  in  bilateral  renal  tuberculosis,  or  when  it  has  failed,  as  in  per- 
sistent tuberculous  cystitis  after  nephrectomy  for  unilateral  renal  tuberculosis, 
more  direct  measures  are  necessary. 

Tuberculin  treatment  is  the  most  successful  method,  and  the  most  favour- 
able cases  are  those  where  the  original  focus  of  tubercle  has  already  been 
removed.  Where  the  infection  is  mixed,  vaccines  should  be  used  alternatively 
with  the  tuberculin  injections. 

Local  treatment  by  washing,  or  by  instillation  of  various  drugs,  is  highly 
recommended  by  some  authorities.  The  best  known  of  these  methods  is  the 
repeated  instillation  of  5  per  cent  carbolic  acid  recommended  by  Rovsing. 
Good  results  are  claimed  for  this  treatment,  but  exact  figures  are  not  available. 
With  all  these  methods  there  is  a  danger  of  introducing  sepsis  and  producing 
a  mixed  infection.  J.  W.  Thomson  Walker. 

BONE  TUMOURS. — We  have  to  consider  the  following  growths  of  bone  : 
osteoma,  chondroma,  sarcoma,  carcinoma,  multiple  myeloma,  'thyroid  cancer,' 
and  cysts.     Epulis  is  discussed  elsewhere  {see  Jaws,  Growths  of). 

Several  of  the  above  can  be  dismissed  with  a  few  words. 

Osteoma.— Ivory  osteoma,  usually  arising  about  the  orbits  or  on  the  jaw, 
is  a  progressive  tumour  of  extremely  slow  but  steady  growth,  and  does  no  harm 
unless  it  presses  on  important  structures. 

Cancellous  osteomata  and  exostoses  are  usually  capped  by  cartilage  which 
ossifies  at  about  twenty-one  to  twenty-four,  when  the  growth  of  the  skeleton 
ceases,  so  that  the  exostosis  attains  its  maximum  at  that  age.  Large  sessile 
cancellous  osteomata  may,  however,  go  on  growing. 

Complete  removal  is  not  followed  by  recurrence. 


BONE     TUMOURS  107 


Chondroma. — A  pure  chondroma,  such  as  may  be  found  on  the  fingers  of 
young  adults,  grows  slowly  but  progressively,  and  is  not  dangerous  to  life, 
and  does  not  recur  after  removal. 

Large,  rapidly-growing  cartilaginous  tumours  on  a  bone  are  usually  to  be 
classed  with  the  periosteal  sarcomata  undergoing  degeneration,  and  are  very 
malignant. 

Myeloid  Sarcoma. — By  this  we  mean  a  very  vascular,  usually  deep-red,  central 
tumour  expanding  the  bone,  containing  a  great  number  of  giant  cells  under  the 
microscope.  It  must  be  remembered  that  a  central  tumour  of  bone  is  not 
necessarily  myeloid  ;  it  may  be  a  malignant  sarcoma,  but  this  is  uncommon. 
The  older  literature,  including  much  of  that  utilized  in  Butlin's  Operative 
Surgery  of  Malignant  Disease,  is  quite  unreliable  in  its  description  of  the 
exact  nature  of  the  growth.  He  collected  from  the  literature  the  following 
cases  of  '  central  sarcoma  ' : — 

Humerus. — 10  cases  ;  3  died  of  recurrence  or  metastasis  (two  of  which  were 
myeloid)  ;  5  well,  one  to  three  years  ;  2  well,  over  three  years.  In  most  of 
these,  Berger's  amputation  was  performed. 

Radius  and  Ulna. — 10  cases  :  i  died  of  recurrence  (probably  not  myeloid)  ; 
3  well,  one  to  three  years  ;    6  well,  over  three  years. 

Femur. — 14  cases  :  5  died  of  metastasis  (3  of  these  were  myeloid)  ;  2  recurred 
in  situ  ;  2  were  well  one  to  three  years  later  ;  5  were  well  over  three  years. 
Nearly  all  these  were  treated  by  amputation. 

Tibia  and  Fibula. — 20  cases  :  2  died  of  metastasis  or  recurrence  (round-celled 
sarcoma,  not  myeloid)  ;  9  well  from  one  to  three  years  ;  9  well  over  three  years. 
Here  again,  nearly  all  were  amputated. 

It  will  be  observed,  therefore,  that  in  five  cases  myeloid  gave  rise  to  fatal 
metastases,  but  that  23  were  well  one  to  three  years  after,  and  a  further  22  were 
well  over  three  years. 

Coming  to  more  modern  investigation,  we  find  that  there  is  a  general 
consensus  of  opinion  that  myeloid  is  practically  an  innocent  tumour,  and  it 
is  very  unusual  for  metastasis  to  occur  when  the  diagnosis  has  been  made  by 
a  reliable  microscopist.  The  writer  knows  of  one  recent  case  in  which  fatal 
secondaries  appeared  in  the  lung. 

On  the  other  hand,  Bloodgood  reports  that  18  cases  seen  by  himself  are  all 
alive  and  well ;  he  added  to  this  from  the  literature,  and  finds  that  of  26  treated 
by  curetting  out,  5  recurred,  but  none  formed  secondaries  ;  the  other  21  were 
cured.  Of  22  resected,  i  recurred  and  was  amputated  ;  the  rest  did  well.  Eve 
reports  7  cases  treated  at  the  London  Hospital  by  amputation,  resection,  or, 
in  one  case,  scraping  ;    all  were  well  from  one  and  a  half  to  ten  years  after. 

Eight  cases  treated  in  Bristol  by  resection  or  scraping  out  have  all  done  well, 
except  that  local  recurrence  took  place  in  two  cases  scraped  out. 

We  may  conclude,  therefore,  that  the  risk  of  metastasis  in  the  lungs  exists, 
but  is  quite  small,  that  inadequate  local  operations  may  be  followed  by  recur- 
rence in  situ,  but  that  almost  all  cases  can  be  cured  by  an  adequate  operation. 
Amputation  is  only  occasionally  necessary,  as,  for  instance,  if  the  bony  shell 
over  the  growth  is  very  thin,  and  so  great  a  length  would  have  to  be  resected 
as  to  make  the  limb  useless. 

The  operation  mortality  quoted  by  Butlin  relates  to  ancient  surgery  ;  nowa- 
days the  risks  are  very  small,  probably  not  more  than  i  or  2  per  cent. 

Periosteal  Sarcoma.- — It  is  difficult  to  obtain  accurate  accounts  of  the 
prognosis  of  this  disease  from  the  literature,  because  so  many  statistics  are 
hopelessly  vitiated  by  the  inclusion  of  cases  of  myeloid,  or  what  is  described  as 
"  mixed  round  or  spindle  cells  and  giant  cells,"  which  usually  means  myeloid. 


io8  INDEX     OF     PROGNOSIS 

When  this  fallacy  is  eliminated,  it  becomes  difficult  to  find  cases  of  cure  in 
patients  with  a  genuine  round-  or  spindle-celled  sarcoma.  The  fiat  bones  give 
better  results  than  the  long  bones. 

Kocher  could  only  collect  15  instances  of  cure  of  periosteal  sarcoma  of  the 
long  bones,  after  amputation,  in  1906.  The  more  favourable  statistics  of 
Wyeth,  Bergmann,  and  the  Tubingen  clinic,  all  include  endosteal  growths. 

Alexis  Thomson  records  5  periosteal  sarcomas  of  the  femur  and  2  of  the  humerus 
treated  by  amputation  (Berger's  in  the  latter  cases),  but  only  one  remained 
well,  a  femur  patient  being  alive  two  and  a  half  years  after.  Nancrede 
published,  in  1909,  the  end-results  of  65  cases  of  excision  of  the  scapula  for 
sarcoma.  They  were  as  follows  :  10  cases  insufficiently  followed  ;  35  cases 
died  within  two  years  ;  7  cases  well  over  four  years.  Death  usually  took  place 
within  a  year  (26  cases).  In  one  case  recurrence  was  as  late  at  five  years  after- 
wards. The  writer  has  seen  an  unpublished  case  of  mixed-celled  sarcoma 
well  more  than  three  years  after  removal  of  the  blade  of  the  scapula.  The 
operation  mortality  in  Nancrede's  series  was  about  10  per  cent. 

Sarcoma  of  the  Humerus  is  terribly  malignant.  The  mortality  of  Berger's 
operation  since  1887  is  about  6  per  cent  (Chavasse,  Barling,  Dent,  quoted  by 
Butlin).  The  only  case  of  cure  mentioned  by  Butlin  in  which  the  diagnosis 
was  microscopically  confirmed,  was  a  growth  of  the  lower  end  of  the  humerus 
amputated  in  Gottingen,  and  well  at  least  eight  years  afterwards. 

Sarcoma  of  the  Femur  is  common,  and  very  malignant.  The  mortality 
of  amputation  at  the  hip-joint  was  considered  to  be  about  12  per  cent,  but  is 
probably  less  at  the  present  time.  In  Butlin's  series  of  68  cases,  only  2  lived 
for  three  j'ears  ;  i  of  these  had  had  a  growth  for  seven  years,  and  it  is  not 
certain  that  the  other  was  a  periosteal  sarcoma. 

A  case  treated  by  local  removal  at  the  Bristol  Royal  Infirmary  in  1910, 
associated  with  repeated  fractures  in  1904,  1906,  and  1910,  was  seen  apparently 
cured  in  September,  1913.  The  microscopical  report,  by  a  front-rank  pathologist, 
was  fibro-sarcoma. 

Sarcoma  of  the  Tibia  or  Fibula. — In  a  series  of  35  cases,  ButHn  found  i  alive 
and  well  after  seven  years,  and  4  well  between  one  and  two  years.  The  patient 
apparently  cured  had  had  the  growth  for  eight  years  before  operation.  A 
case  at  the  Bristol  Royal  Infirmary  treated  by  amputation  was  quite  weU  when 
last  seen,  fifteen  months  later. 

Recurrence  is  not  usual  in  the  stump,  but  the  patient  dies  of  metastases 
in  the  chest,  with  groin  glands  also  invaded  in  many  cases. 

Sarcoma  of  the  Skull. — Although  of  course  the  great  majority  of  these  cases 
are  very  unfavourable  and  proceed  to  a  fatal  termination  in  six  to  twelve  months, 
with  pressure  on  the  brain,  or  an  external  fungating  swelling,  there  are  a  few 
instances  in  which  the  growth  appears  to  be  less  malignant  in  nature.  One 
such,  removed  at  the  Bristol  Royal  Infirmary  in  1904,  recurred  in  1908,  and 
was  then  the  size  of  a  hen's  egg  ;  it  was  again  removed,  and  four  years  later 
the  patient  was  known  to  be  well,  and  is  almost  certainly  still  alive,  though 
out  of  England.  The  microscopical  diagnosis  was  fibro-sarcoma.  In  another 
case  seen  by  the  writer,  the  growth,  a  spindle-celled  sarcoma,  was  stationary 
for  five  years  (further  history  not  known)  after  injections  of  Coley's  fluid. 
Jacobson  and  Morris  both  record  patients  Hving  for  five  or  six  years  after  the 
first  appearance  of  the  growth.  Bergmann  claims  to  have  cured  5  (how  long 
followed  is  not  stated)  out  of  17  cases  operated  on.  Some  tumours  of  the  skull 
are  myeloid  in  nature,  and  may  yield  better  results. 

Sarcoma  and  Carcinoma  of  the  Jaws  are  discussed  elsewhere  {see  Jaws, 
Growths  of.) 


BONE     TUMOURS  109 


It  will  be  gathered  from  the  data  given  that  sarcoma  of  the  long  bones  is 
almost  never  cured  by  amputation,  except  when  it  is  obviously  very  chronic, 
but  that  in  the  fiat  bones  there  is  some  slight  prospect  of  cure. 

The  results  in  children  are  much  the  same  as  in  adults.  Rawling  has  collected 
cases  in  the  literature  of  bone  sarcoma  affecting  children  under  nine  years. 
Of  59  cases,  only  i,  a  patient  with  congenital  sarcoma  of  the  scapula  treated 
by  local  removal  at  five  months,  was  followed  up  and  found  to  be  cured  several 
years  after. 

Two  other  methods  of  treatment  call  for  some  consideration. 

Coley's  Fluid. — There  are  cases  on  record,  one  of  which  (a  sarcoma  of  the 
orbit)  the  writer  has  seen,  where  a  sarcoma  has  disappeared  after  an  attack  of 
erysipelas,  and  Coley  has  steadfastly  maintained  the  value  of  his  mixed  toxins 
of  erysipelas  and  Bacillus  prodigiosus  as  a  curative  agency  in  sarcoma. 

Although  the  treatment  was  at  first  adversely  reported  on  by  an  American 
surgical  committee,  Coley  subsequently  convinced  its  members  and  won  them 
over  to  his  side.  The  results  in  England  are  not  so  favourable  as  in  America, 
but  the  writer  has  seen  a  patient  with  sarcoma  of  the  temporal  region,  explored, 
microscoped,  and  found  inoperable,  cured  and  followed  for  many  years  after 
the  treatment ;  and  a  lad  with  sarcoma  of  the  foot  similarly  treated  has  remained 
in  statu  quo  for  more  than  three  years.  There  have  been,  of  course,  a  number 
of  failures  besides. 

Coley  claims  to  have  cured,  and  followed  up  for  three  or  more  years,  4  cases 
of  periosteal  sarcoma  of  the  femur  and  one  of  the  tibia  ;  all  except  i  femur 
case  were  also  amputated.  This  patient  eventually  died,  more  than  ten  years 
after,  of  a  mixed  epithelioma-sarcoma  in  the  scar  of  an  x-Ta.y  burn.  Eve 
also  reports  a  case  of  sarcoma  of  the  femur  amputated  and  treated  by  Coley's 
fluid,  well  frwo  and  a  half  years  afterwards,  but  in  10  other  cases  the  fluid  did 
no  good.  In  other  situations  (muscle,  etc.),  the  injections  are  said  to  have 
cured  over  100  cases  of  sarcoma,  followed  three  years  or  more  afterwards. 

In  our  opinion,  the  combination  of  amputation  with  Coley's  fluid  following, 
gives  a  patient  the  best  chance,  and  of  the  two  we  have  more  faith  in  the 
injections  for  sarcoma  of  the  long  bones. 

Radium. — In  one  case  known  to  the  writer,  radium  treatment  has  a.rrested 
the  growth  of  a  sarcoma  of  the  femur  for  over  a  year,  but  it  is  too  soon  yet 
to  speak  of  radium  cures. 

Carcinoma  of  Bone. — This  is  always  secondary,  usually  to  cancer  of  the  breast, 
and  is  apt  to  lead,  in  the  humerus,  to  spontaneous  fracture,  and  in  the  spine 
to  great  pain  and  pressure  on  the  cord.  By  this  time  this  patient  is  nearly 
always  within  a  few  months  of  the  inevitable  end. 

Multiple  Myeloma,  Myelopathic  Albumosuria,  Kahler's  Disease. — This  disease, 
characterized  by  endosteal  swellings  in  various  bones  and  a  peculiar  albumose 
called  Bence-Jones  protein  in  the  urine,  is  usually  very  malignant  and  runs  a 
rapid  course,  killing  the  patient  in  about  two  years. 

The  writer  has  seen  a  case,  however,  under  the  care  of  Mr.  Hey  Groves,  in 
which  the  disease  was  arrested  naturally,  and  the  patient  was  living  and  well 
after  many  years,  but  severely  crippled  by  badly  united  spontaneous  fractures. 

"  Thyroid  Cancer." — In  this  curious  condition  a  tumour  appears  on  the  skull 
or  sternum,  often  pulsating,  having  the  structure  of  thyroid  tissue,  and  associated 
with  an  enlarged  or  cancerous  thyroid.  The  English  cases  all  died,  but  Goebel 
relates  some  successful  removals  of  the  growth  in  bone. 

Bone  Cysts. — Cysts  of  bone  are  either  of  the  nature  of  ostitis  fibrosa  which 
has  developed  central  cystic  cavities,  or  hydatid  cysts,  usually  in  the  lumbar 
vertebra;  or  hip  bone. 


INDEX     OF     PROGNOSIS 


Simple  bone  cysts  of  the  former  variety  reach  a  certain  size  and  then  remain 
stationary  throughout  Hfe,  giving  rise  sometimes  to  spontaneous  fractures. 
Bloodgood  reports  the  results  of  operation  on  38  cases  treated  by  curetting  ; 
2  died  of  hjemorrhage,  in  another  amputation  was  necessary  for  the  same 
reason,  and  the  other  35  did  well. 

Hydatid  cysts  of  the  spine  are  apt  to  enlarge  progressively  and  press  on  the 
cord,  but  the  results  of  operation  are  satisfactory. 

References. — Butlin,  Operative  Surgery  of  Malignant  Disease,  second  ed.  1900  ; 
Bloodgood,  Ann.  Surg.  1910,  lii,  145  ;  Ibid.  1912,  Ivi,  210  ;  Eve,  Lancet,  1912,  ii,  1355  - 
Alexis  Thomson,  Edin.  Med.  Jour.  1907,  Ixiv,  423;  Nancrede,  Ann.  Surg.  1909,  1,  i ; 
Rawling,  Lancet,  1907,  i,  352  ;  Coley,  Ann.  Surg.  1907,  xlv,  321  ;  Colev,  Proc.  Roy. 
Sac.  Med.  1910  (Surg.  Sect.)  i  ;  Goebel,  Deut.  Zeit.  f.  Chirurg.  1898  ;  Groves,  Ann. 
S»rg.  1913,  Ivii,  163.  A.  Rendle  Short. 

BRACHIAL  PALSY.— (5ee  Nerve  Injuries.) 

BREAST,  CANCER  OF. 

Prognosis  apart  from  Operation. — To  foretell  the  duration  of  Hfe  in  a  patient 
with  breast  cancer  is  one  of  the  most  difficult  problems  which  can  confront  the 
medical  man.  Indeed  in  many  cases  no  answer  whatever  can  be  given.  This 
is  not  surprising  when  it  is  borne  in  mind  that  in  the  worst  cases  the  disease  may- 
run  its  course  in  three  months,  while  at  the  other  end  of  the  scale  the  patient 
may  live  for  thirty  years  or  more  -wdth  a  cancer  which  during  the  whole  of  that 
time  shows  some  evidences  of  activity.  But  there  are  certain  varieties  of  breast 
cancer  in  which  a  definite  prognosis  is  possible. 

Acute  Breast  Cancer. — If  the  whole  breast  is  involved  in  a  large  swelling 
which  is  everywhere  adherent  to  the  skin,  if  also  the  breast  is  fixed  to  the  deep 
fascia,  if  enlarged  hard  glands  are  present  in  the  axilla,  and  more  especially  if 
the  skin  over  the  tumour  shows  a  red  blush,  it  can  be  stated  almost  with  certainty 
that  the  patient  will  be  dead  in  six  months,  and  that  no  operation  is  of  the  least 
use. 

Atrophic  Scirrhus. — In  certain  cases  in  old  people  the  nipple  may  be  sHghtly 
in-drawn,  or  a  definite  local  depression  may  make  its  appearance  at  some  point 
in  the  skin  over  the  breast,  while  the  whole  breast  becomes  somewhat  shrunken  ; 
no  tumour  can  be  felt  in  the  breast,  nor  are  the  glands  enlarged.  Such  a  case 
is  an  example  of  atrophic  scirrhus  in  its  extreme  form,  and  it  is  possible  to 
assert  that  the  patient  will  probably  go  on  for  a  number  of  years  without  pain 
or  trouble  of  any  kind.  Ultimately,  however,  and  especially  if  the  breast  is 
too  freely  examined  or  massaged,  it  is  probable  that  a  tumour  will  develop, 
that  the  glands  will  become  enlarged,  and  that  the  case  will  then  slowly  run 
the  ordinary  course  of  breast  cancer.  But  if,  as  frequently  happens,  the  patient 
is  already  old  when  the  tumour  is  discovered,  the  probabihties  are  that  she 
will  die  of  some  other  condition. 

In  the  less  tj'pical  forms  of  atrophic  scirrhus,  a  small  hard  lump  is  present 
which  changes  its  character  but  httle  for  extensive  periods  of  time.  In  such 
cases  a  prognosis  of  some  years'  duration  of  life,  say  up  to  ten,  may  be  given 
with  probable  approach  to  accuracy. 

Carcinoma  during  Lactation. — If  a  breast  cancer  de\'elops  during  lactation, 
although  it  may  make  little  progress  so  long  as  suckling  is  continued,  it  will 
probably  grow  rapidly  Avhen  the  milk  ceases  to  be  secreted,  and  the  prognosis  is 
a  bad  one. 

Mastitic  form  of  Carcinoma. — As  a  rule,  cancer  of  the  breast  forms  a  rounded 
lump  which  bears  no  relation  to  the  anatomical  outlines  of  the  lobes  of  the 
breast,  but  there  are  certain  cases  where  the  cancer  commences  throughout  the 


BREAST.     CANCER     OF 


substance  of  one  or  more  lobes.     Such  cases  generally  originate  as  a  chronic 

mastitis.  The  tumour  formed  resembles,  in  its  sector-shape,  the  thickenings  of 
chronic  mastitis  ;  that  is  to  say,  it  marks  out  the  limitations  of  one  lobe  or  a 
group  of  lobes.  A  diagnosis  may  be  difficult,  but  this  question  does  not  now 
concern  us.  It  must  be  recognized  that  this  form  of  carcinoma,  perhaps  owing 
to  its  multicentric  or  diffuse  origin,  is  of  particularly  bad  prognosis,  and  that 
recurrence  is  likely  to  take  place  within  a  year  after  operation. 

Duct  Carcinoma. — The  recent  work  of  Mr.  Lenthal  Cheatle  has  shown  that 
duct  carcinoma  is  much  commoner  than  has  been  supposed,  and  that  it  is 
probably  almost  as  frequent  as  carcinoma  originating  in  the  acini ;  but  the 
typical  form  of  duct  carcinoma  of  the  large  ducts,  which  originates  beneath 
the  nipple  in  women  of  advanced  years  without  causing  retraction  of  the  nipple, 
is  a  comparatively  benign  tumour  and  runs  a  somewhat  slow  course.  The 
prognosis  after  operation  is  distinctly  good. 

Ordinary  Scirrhus. — It  is  only  in  the  exceptional  forms  of  breast  cancer  that 
a  definite  opinion  as  to  duration  of  life  can  be  expressed.  In  the  ordinary 
scirrhus  of  the  breast  not  operated  upon,  cases  which  are  apparently  similar 
may  hve  for  varying  periods.  The  younger,  stouter,  and  more  healthy-looking 
the  patient,  the  shorter  is  life  likely  to  be  if  no  operation  is  performed.  So  long 
as  the  disease  confines  itself  to  the  parietes  of  the  body,  and  does  not  involve 
the  visceral  cavities,  duration  of  life  remains  uncertain  ;  but  from  my  experience 
I  can  state  with  some  confidence  that  when  there  are  visceral  deposits,  whether 
in  the  chest,  abdomen,  or  head,  the  patient's  life  is  unhkely  to  be  prolonged 
more  than  a  year.  Many  die  within  six  months  after  the  first  onset  of  visceral 
deposit. 

Prognosis  as  regards  Recovery  from  Operation. — Although  the  modern  opera- 
tion for  breast  cancer  is  apparently  a  severe  one,  it  does  not  produce  marked 
shock  if  care  is  taken,  especially  in  regard  to  preventing  chill  during  the 
operation.  Even  old  persons  stand  it  well.  Nevertheless,  in  hospital  practice 
there  is  a  definite  death-rate,  mainly  due  to  the  risk  of  infection  arising  from 
the  collection  of  mixed  surgical  cases  in  one  ward.  This  risk  may  be  placed 
at  from  i  to  2  per  cent.  My  personal  experience  in  hospital  practice  includes 
the  loss  of  cases  from  influenza  (at  the  time  of  an  epidemic),  erysipelas,  broncho- 
pneumonia, and  pulmonary  embohsm.  In  a  nursing  home  or  private  house, 
on  the  other  hand,  I  have  never  lost  a  case,  a  fact  which  appears  to  show  con- 
vincingly that  the  belief  that  a  hospital  is  the  safest  place  for  operation  is  not 
borne  out  by  experience. 

Prognosis  as  regards  Recurrence  after  Operation. — It  cannot  be  too  strongly 
emphasized  that  the  prognosis  after  an  operation  for  breast  cancer  is  largely 
dependent  upon  the  thoroughness  with  which  the  operation  is  performed. 
Axillary  recurrence,  v/hich  is  hardly  ever  seen  after  a  thorough  operation,  is 
common  after  the  inadequate  ones  which  are  the  far  too  frequent  handiwork 
of  the  '  occasional  '  surgeon. 

As  regards  operation  statistics,  it  may  be  doubted  whether  they  are  of  great 
▼alue,  since  they  depend  so  largely  upon  the  stage  at  which  the  case  is  first 
seen,  upon  the  mode  of  selection  of  cases  regarded  as  suitable  for  operation, 
and  upon  the  thoroughness  of  the  operation. 

In  my  own  series  of  cases,  perhaps  an  unduly  large  proportion  have  been 
advanced  ones  ;  moreover,  no  case,  however  late,  has  been  refused  operation 
if  there  seemed  to  be  any  reasonable  prospect  of  benefit.  Of  the  cases  I  have 
been  able  to  trace,  rather  more  than  50  per  cent  have  remained  free  from 
recurrence  for  three  years  and  upwards.  It  is  probable  that  further  improve- 
ment on  these  results  must  be  sought  in  the  better  education  of  the  public  to 


INDEX     OF     PROGNOSIS 


a  recognition  of  the  early  signs  of  cancer.  It  would  not  be  fair  to  attempt  to 
improve  them  by  a  more  rigid  selection  of  cases,  for  the  practice  of  operation 
for  statistics  is  now  rightly  condemned  by  surgical  opinion.  Included  in  my 
series  are  two  cases,  which  were  both  absolutely  inoperable  by  all  ordinary 
rules,  in  which  the  patients  were  able  to  do  full  work  for  periods  of  five  and  two 
years  respectively  after  the  operation. 

Amongst  the  cases  of  cancer  of  the  breast  operated  on  by  Dr.  Halsted  and  his 
associates  in  the  Johns  Hopkins  Hospital  and  other  hospitals  in  Baltimore,  the 
cures  reckoned  five  years  after  the  operation  are  about  40  per  cent.  If,  however, 
the  cancer  is  seen  in  such  an  early  stage  that  the  diagnosis  can  only  be  made  by 
an  exploratory  incision,  and  if  the  complete  operation  followed  immediately  on 
the  exploratory  incision,  80  per  cent  of  the  patients  remained  well  after  five 
years.  According  to  Bloodgood,  who  gives  these  statistics,  the  outlook  is 
entirely  different  if  the  radical  operation  is  not  carried  out  at  the  same  sitting 
as  the  exploratory  one.  Should  an  interval  elapse  between  these  two  procedures, 
Bloodgood  states  that  the  probability  of  the  five-year  cure  is  reduced  from  80 
per  cent  to  about  13  per  cent.  The  experience  of  Bloodgood  in  this  respect  is 
not  in  accordance  with  my  own.  I  do  not  believe  there  is  much  danger  in  the 
separation  by  a  short  interval  between  the  exploratory  and  the  radical  operation, 
although  it  is  desirable  to  combine  the  two. 

The  most  favourable  indubitable  statistics  of  the  operation  for  breast  cancer 
are  those  recently  obtained  by  Professor  W.  R.  Rodman,  of  Philadelphia,  and 
brought  forward  by  him  at  the  London  Clinical  Congress  of  American  Surgeons 
in  August,  1914.  These  statistics  refer  to  50  private  cases  operated  upon  three 
or  more  years  ago.  Of  this  number,  13  are  dead,  i  has  a  recurrence  in  the 
mediastinum  after  three  years  of  apparent  good  health  and  is  accordingly 
reckoned  among  the  dead,  and  the  remaining  cases,  constituting  72  per  cent  of 
the  total,  are  well  after  three  years.  As  Dr.  Rodman  says,  these  results  could 
not  be  obtained  in  hospital  practice.  Private  patients  apply  earher,  offer  better 
resistance,  and  will  keep  under  observation  indefinitely,  thus  permitting  a  second 
operation  if  necessary.  Several  of  his  cases  have  been  saved  by  second  opera- 
tion, a  point  in  which  his  experience  agrees  with  my  own.  Dr.  Rodman  adds 
that  some  of  his  cases  were  so  early  that  a  clinical  diagnosis  of  cancer  could  not 
possibly  be  made  until  after  histological  examination.  These  results,  which 
have  not  been  equalled  in  this  country,  probably  indicate  that  in  the  United 
States  the  public  are  better  educated  in  regard  to  the  danger  of  cancer,  and 
dreading  operation  less,  seek  advice  in  an  early  stage  of  the  disease.  The 
further  improvement  of  English  results  depends  upon  the  education  of  the  public 
in  this  direction. 

I  may  add  that  Dr.  Rodman  accepts  my  own  conclusions  as  to  the  mode  of 
dissemination  of  carcinoma,  and  that  the  operation  he  practises  is  in  accordance 
with  the  conclusions  of  the  permeation  theory  of  dissemination. 

Prognosis  after  Recurrence. — It  is  too  much  the  custom  to  abandon  hope 
and  sit  with  folded  hands  when,  after  an  operation  for  breast  cancer,  recurrence 
has  declared  itself.  It  is  true  that  in  such  cases  the  ultimate  outlook  is  generally 
bad  ;  but  if  the  recurrence  is  recognized  promptly  and  treated  vigorously,  it 
may  be  possible  to  prolong  the  patient's  life  for  at  any  rate  some  years. 

After  the  modern  operation  for  breast  cancer,  recurrence,  if  it  takes  place, 
will  usually  be  found  in  one  of  two  places  :  either  in  the  upper  intercostal  spaces — 
second,  third,  and  fourth — originating  from  glands  of  the  anterior  mediastinum 
which  were  already  infected  at  the  time  of  the  operation,  or  it  may  be  found  in 
the  supraclavicular  glands.  Submammary,  cutaneous  and  fascial,  subclavian, 
or  visceral  recurrence  may  also  occur. 


BREAST,     CANCER     OF  113 


Intercostal  Recurrence. — The  first  variety  of  return  may  be  described  as 
intercostal  recurrence.  It  should  be  treated  by  the  use  of  secondary  x  rays. 
An  injection  of  a  suspension  of  bismuth  carbonate  is  made  at  the  edge  of  the 
sternum  in  the  infected  space  or  spaces,  and  the  area  is  subsequently  vigorously 
;i^-rayed.  I  have  more  than  once  seen  the  recurrence  vanish  under  this  treatment, 
which  I  have  now  used  for  over  four  years  ;  sometimes,  on  the  other  hand, 
the  disease  proceeds  on  its  course  unchecked.  One  of  my  patients  with  this 
apparently  hopeless  form  of  recurrence  has  now  been  well  over  three  years  since 
the  ;t-ray  treatment  commenced.  Treatment  by  radium  may  prove  equally 
efficacious,  or  more  so,  but  only  time  and  experience  can  settle  the  point. 

Supraclavicular  Recurrence. — If  the  patient  is  seen  at  regular  intervals  sub- 
sequently to  the  primary  operation,  and  is  carefully  examined,  recurrence  in 
the  supraclavicular  glands  will  be  detected  at  a  time  when  the  glands  are  still 
freely  movable  and  not  of  great  size.  In  these  circumstances  there  can  be  no 
doubt  whatever  that  the  right  treatment  is  operative  ;  but  it  is  useless  to  perform 
a  hmited  form  of  operation  restricted  to  the  parts  below  the  omohyoid.  The 
whole  of  the  posterior  triangle  must  be  cleared  of  its  glands,  from  the  mastoid 
process  down  to  the  sternoclavicular  joint,  and  outwards  as  far  as  the  edge  of 
the  trapezius.  The  tissues  containing  the  glands  should  be  removed  in  one 
piece.  The  operation  required  is  an  extensive  one,  and  it  is  necessary  to  open  the 
carotid  sheath,  and  to  carry  the  dissection  down  to  the  near  neighbourhood  of 
the  thoracic  duct,  removing  all  the  tissues  between  the  sternomastoid  and  the 
scalenus  anticus.  The  operation  is  not  one  which  should  be  undertaken  by  the 
inexperienced.  My  experience  shows  that  freedom  for  three  years  or  more 
may  be  hoped  for,  and  that  almost  always  the  patient  will  be  freed  from  the 
terrible  prospect  of  a  mass  of  growth  fixed  to  the  brachial  plexus  and  causing 
agonizing  pain.  If  the  disease  returns,  it  is  likely  to  do  so  in  a  painless  form 
within  the  chest. 

The  foregoing  remarks  apply  to  early  supraclavicular  recurrence.  If  the 
glands  are  large,  and  especially  if  they  are  fixed,  an  operation  is  rarely  advisable, 
and  if  it  is  performed,  local  recurrence  is  very  likely  to  take  place.  In  this  event 
the  recurrence  will  be  a  diffuse  one,  and  the  patient's  condition  is  rather  aggra- 
vated than  improved  by  the  operation. 

Submammary  Recurrence. — If  after  an  operation  nodules  appear  over  a  region 
corresponding  to  the  area  of  contact  of  the  breast  with  the  chest  wall,  and  if 
these  nodules  are  adherent  to  the  ribs  and  muscles  but  not  to  the  skin,  it 
may  be  inferred  that  at  the  time  of  the  operation  permeation  had  extended 
into  the  lymphatics  of  the  intercostal  muscles.  Under  these  circumstances 
recurrence  is  of  course  inevitable,  unless  the  prophylactic  course  of  x  rays  is 
able  to  destroy  the  remaining  cancerous  foci.  This  form  of  recurrence,  though 
unavoidable,  is  fortunately  not  common.  It  may  be  spoken  of  as  submammary 
recurrence. 

Cutaneous  and  Fascial  Recurrence. — The  form  of  recurrence  which  follows 
inadequate  operation  for  breast  cancer  is  usually  that  known  as  local  recurrence, 
in  which  nodules  appear  in  or  near  the  scar  of  the  operation.  If  these  nodules 
are  cutaneous,  i.e.,  fixed  to  the  skin,  they  should  be  excised  if  they  are  near  the 
scar  ;  but  if  they  occur  at  the  periphery  of  the  field  of  operation,  or  are  fixed  to 
the  deep  fascia,  they  probably  indicate  inadequate  removal  of  the  deep  fascia, 
with  widespread  and  inoperable  extension  of  the  disease  in  that  layer.  Under 
these  circumstances  the  only  treatment  is  x  rays,  intensified  by  bismuth  injec- 
tions, and  the  ultimate  outlook  is  a  bad  one. 

Subclavian  Recurrence. — When  during  an  operation  for  breast  cancer  the 
subclavian  glands  are  left  behind,  these   glands  are   usually  the  seat  of  recur- 


114  INDEX     OF     PROGNOSIS 

rence.  This  is  a  form  which  is  extremely  likely  to  occur  in  the  practice  of 
inexperienced  operators.  The  subclavian  glands  are  situated  beneath  the 
costocoracoid  membrane,  below  the  clavicle  and  above  the  pectorahs  minor, 
at  the  extreme  apex  of  the  axilla.  Recurrence  in  these  glands  is  indicated  by 
a  lump  deeply  situated  behind  the  pectoralis  major  and  immediately  below  the 
clavicle.  To  this  bone  the  lump  may  become  adherent  in  the  latest  stage, 
simulating  a  deposit  of  cancer  in  the  clavicle  itself. 

The  prognosis  in  subclavian  recurrence  is  a  very  grave  one,  though  operation, 
if  undertaken  early,  and  followed  by  vigorous  radiation,  is  not  entirely  hopeless. 

Visceral  Recurrence. — When  signs  of  the  return  of  the  disease  in  the  interior 
of  the  thorax  or  abdomen  have  made  their  appearance,  it  is  possible  to  give  a 
precise  prognosis.  Before  the  disease  has  reached  the  visceral  cavities,  a  cautious 
man  will  often  refuse  to  give  any  estimate  of  the  duration  of  life  ;  it  may  vary 
from  a  few  months  to  twenty  or  thirty  years.  When  the  signs  of  visceral  return 
are  manifest,  it  is  an  almost  invariable  rule  that  the  patient  will  die  within  a 
period  not  exceeding  a  year,  and  not  usually  exceeding  six  months.  In  such 
cases  treatment  is  of  no  avail,  though  it  has  appeared  to  me  that  sometimes 
open-air  methods  on  the  lines  of  sanatorium  treatment  for  phthisis  have  some- 
what deferred  the  inevitable  result. 

Influence  of  X-Ray  Treatment  on  Prognosis, 

Prophylactic  x  rays. — A  course  of  prophylactic  x  rays  subsequent  to  the 
operation  for  breast  cancer  should  never  be  omitted.  It  is  known  that,  at  any 
rate  in  some  cases,  x  rays  may  cause  the  atrophy  and  disappearance  of  large 
masses  of  cancer  cells.  How  much  more  effective,  therefore,  they  must  be 
when  applied  to  small  undetectable  groups  of  cancer  cells  which  may  possibly 
lurk  in  the  tissues  subsequent  to  an  operation  for  breast  cancer,  especially 
since  by  the  removal  of  the  breast  these  microscopic  groups  are  brought  nearer 
to  the  surface  instead  of  being  protected  by  the  whole  thickness  of  the  breast. 
But  the  value  of  x  rays  does  not  rest  on  a  priori  considerations.  My  own 
experience  conclusively  proves  their  value.  In  my  series  of  cases,  only  four  or 
five  times  has  recurrence  been  observed  in  the  skin  or  subcutaneous  tissues  ; 
in  all  of  these  cases,  with  at  most  one  exception,  the  patient  for  one  reason  or 
another  had  escaped  the  prophylactic  course  of  x  rays  which  I  give  to  all  my 
cases.  The  facts  are  rendered  more  striking  when  it  is  remembered  how  small 
a  proportion  the  cases  which  escaped  post-operative  Ar-ray  treatment  bear  to 
the  total  number  of  cases. 
,  The  value  of  x  rays  in  the  treatment  of  masses  of  cancer  cells  of  macroscopic 
size  is  smaller,  but  an  undoubted  one  ;  such  masses  are  usually  accompanied 
by  wide-spreading  microscopic  ramifications  of  the  disease,  which  may  very 
probably  have  extended  deeply,  e.g.,  to  the  pleura,  beyond  the  range  of  x  raj^s. 
Consequently,  though  these  nodules  may  shrink  or  disappear  in  such  cases, 
.r-ray  treatment  is  usually  only  of  temporary  value. 

Secondary  x  rays. — Professor  C.  G.  Barkla  some  years  ago  called  attention 
to  the  fact  that  metalhc  particles  bombarded  by  x  rays  gave  off  secondary 
X  rays.  He  suggested  the  possible  therapeutic  application  of  this  observation, 
and  for  some  years  past  I  have  been  employing  injections  of  bismuth  carbonate 
in  cases  of  breast  cancer  to  intensify  the  action  of  x  rays  by  acting  as  a  secondary 
source  of  them.  I  am  strongly  of  opinion  that  the  method  is  a  valuable  one, 
and  that  in  certain  cases  it  entirely  alters  the  prognosis.  The  most  striking  of 
my  cases  was  that  of  a  patient  in  whom,  three  years  after  the  operation  for 
breast  cancer,  intercostal  recurrence  showed  itself.  This  form  of  recurrence, 
so  far  as  my  previous  experience  went,  seemed  absolutely  hopeless.  I  injected 
.bismuth  into  the  intercostal  spaces,  and  ;i;-ray  treatment  was  vigorously  carried 


BREAST,     CANCER     OF  113 

out  by  Mr.   C.   R.   Lyster.     The  nodules  completely  disappeared,  and  at  the 
present  time  (three  years  later)  the  patient  remains  quite  well. 

Influence  of  Radium  Treatment  on  Prognosis. — Speaking  generally,  and 
bearing  in  mind  that  radium  has  a  purely  local  action  of  limited  range,  its  field 
of  usefulness  in  cancer  of  the  breast  is  a  very  restricted  one.  This  arises  from 
the  fact  that,  except  in  early  cases  for  which  operation  is  the  only  trustworthy 
treatment,  the  area  of  extension  of  the  disease  is  too  large  to  be  dealt  with  by 
the  amount  of  radium  ordinarily  available.  Owing  to  this  feature  of  the  disease, 
X  rays  provide  a  more  suitable  form  of  radiation.  Occasionally,  however, 
radium  may  possess  the  advantage.  Thus,  for  instance,  in  old  persons  too 
feeble  for  operation,  radium  may  be  buried  in  the  primary  growth  as  a 
preliminary  to  ;ir-ray  treatment,  especially  if  the  growth  is  too  massive  to  be 
penetrated  by  x  rays  from  without.  Radium  is  also  suitable  for  the  treatment 
of  localized  recurrent  nodules  which  resist,  or  are  not  easily  accessible  to,  x  rays. 

Marked  and  complete  retrogression  may  occur  in  local  masses  of  cancer  cells 
subjected  to  radium,  but  only  in  very  rare  cases  can  a  cure  of  the  disease  be 
even  hoped  for — namely,  in  cases  where  such  a  single  mass  of  cancer  cells  is  the 
only  focus  of  growth  present,  and  is  unaccompanied  by  microscopic  extensions 
of  the  disease  in  other  parts. 

Influence  of  Pleural  Adhesions  on  Prognosis. — It  is  an  interesting  fact,  and 
one  which  should  be  taken  into  account  in  estimating  prognosis,  that  obhtera- 
tion  of  the  pleural  cavity  checks  dissemination  to  an  appreciable  extent.  This 
I  have  been  able  to  show  by  analysis  of  the  statistics  of  the  Middlesex  Hospital 
cancer  wards.  Marked  pleural  adhesions  were  present  in  37  of  the  329  cases. 
Cancerous  invasion  of  the  pleura  was  present  in  only  11  of  these  37  cases,  or 
30  per  cent,  while  of  the  sum  total  of  Middlesex  Hospital  cases  44  per  cent 
showed  pleural  invasion.  In  3  of  these  11  cases  the  adherent  pleura  on  the 
side  of  the  growth  had  escaped  invasion,  while  the  opposite  non-adherent  pleura 
was  cancerous. 

Doubt  may  at  first  appear  to  be  thrown  on  this  evidence  of  the  protective 
action  of  an  adherent  pleura  by  the  fact  that  only  30  per  cent  of  the  cases  with 
pleural  adhesions  were  absolutely  free  from  metastases  as  compared  with  33 
per  cent  of  the  sum  total  of  cases.  But  the  protective  action  of  an  adherent 
pleura  extends  only  to  the  thoracic  cavity.  It  has  been  shown  that  in  a  large 
proportion  of  cases  invasion  of  the  abdomen  occurs,  not  by  way  of  the  thorax, 
but  directly  through  the  epigastric  parietes.  Pleural  adhesions  do  not  check 
this  process  :  perhaps,  indeed,  their  resistance  to  the  deep  extension  of  the 
growth  may  accelerate  the  progress  of  fascial  permeation,  and  so  actually  favour 
epigastric  invasion.  It  is  a  most  striking  fact  that  32  per  cent  of  the  37  cases 
with  marked  pleural  adhesions  showed  the  abdomen  invaded  by  cancer  and 
the  chest  free,  while  only  12  per  cent  of  a  total  of  329  cases  showed  a  similar 
state  of  affairs.  The  converse  difference  is  equally  striking.  While  22  per  cent 
of  the  Middlesex  Hospital  necropsies  show  the  thoracic  cavity  invaded  and  the 
abdomen  free,  only  5  per  cent  of  the  cases  with  pleural  adhesions  show  a  similar 
state  of  affairs.  These  facts  are  a  strong  indirect  testimony  both  to  the  frequency 
of  epigastric  invasion  and  to  the  protection  afforded  by  pleural  adhesions  to 
the  thoracic  cavity.  Incidentally  they  provide  a  strong  argument  against  the 
embolic  theory,  by  showing  that  invasion  of  the  abdomen  and  invasion  of  the 
thorax  are  independent  events. 

The  foregoing  facts  convey  a  therapeutic  suggestion — namely,  that  if  the 
pleural  cavity  on  the  affected  side  could  be  obliterated  by  artificially  induced 
adhesions,  hfe  might  be  prolonged.  Unfortunately,  the  injection  of  irritant 
fluids  into  the  pleura  is  known  to  be   attended   by  danger.     In  two  cases  in 


ii6  INDEX     OF     PROGNOSIS 

which  there  was  evidence  of  early  pleural  involvement  at  the  base  of  one  lung 
I  have  injected  radium  emanation,  and  a  sterilized  suspension  of  bismuth  car- 
bonate, respectively.  In  the  latter  case  the  injection  was  made  as  a  preUminary 
to  ;v-ray  treatment.     In  neither  case  was  a  definitely  favourable  result  attained. 

W-  Sampson  Handley- 

BREAST,  SIMPLE  DISEASES  OF.— We  shall  consider  the  prognosis  of  : 
(i)  Chronic  mastitis  ;  (2)  Tuberculosis  ;  (3)  Fibro-adenoma  ;  and  (4)  Paget's 
disease  of  the  nipple.  None  of  these  diseases  involves  any  direct  danger  to  life, 
and  the  interest  of  the  prognosis  centres  around  the  possibility  of  the  subsequent 
development  of  cancer. 

1.  Chronic  Mastitis. — In  young  women  this  condition  presents  no  immediate 
danger.  After  the  age  of  forty,  it  is  to  be  regarded  with  grave  suspicion.  Very 
convincing  evidence  has  now  accumulated  to  show  that  cancer  of  the  breast, 
like  cancer  elsewhere,  is  invariably  preceded  by  chronic  inflammation.  Bryant 
found  a  history  of  mastitis  in  80  out  of  360  cases  of  cancer.  Microscopically, 
Beadles  was  able  to  demonstrate  pre-existing  mastitis  in  every  one  of  100  breasts 
removed  for  cancer  at  the  Brompton  Cancer  Hospital,  although  in  the  majority 
of  the  cases  no  signs  had  been  evident  clinically. 

Quite  apart  from  the  possibility  that  mastitis  may  give  rise  to  cancer,  there 
is  the  very  serious  question  of  the  uncertainty  of  the  diagnosis  of  a  lump  in  the 
breast.  It  is  a  sound  surgical  rule,  at  any  rate  after  the  age  of  thirty-five,  that 
any  lump  in  a  woman's  breast  is  better  out  than  in. 

2.  Tuberculosis. — This  is  a  very  chronic  disease,  with  no  tendency  to  spon- 
taneous cure.  The  breast  eventually  becomes  riddled  with  abscesses,  and  in 
about  20  per  cent  of  cases,  phthisis  finally  develops.  It  is  wise,  therefore,  to 
effect  an  early  clearance. 

3.  Fibro-adenoma. — Generally  speaking,  a  mobile,  well-encapsulated  lump 
in  a  breast,  confidently  diagnosed  as  fibro-adenoma,  is  safe  enough,  and  for 
years  it  does  not  alter  in  size.  Microscopically,  nowever,  it  is  common  to  find 
that  a  recently  observed  tumour  shows  fibro-adenoma  becoming  malignant. 
There  are  a  few  cases  on  record  of  even  old-standing  and  encapsulated  swellings, 
undoubtedly  innocent,  eventually  becoming  carcinomatous.  One  of  these  is 
in  the  museum  of  St.  Bartholomew's  Hospital. 

Removal  of  a  genuine  fibro-adenoma,  verified  as  such  by  the  microscope,  is 
very  rarely  followed  by  recurrence. 

4.  Paget's  Disease  of  the  Nipple. — This  is  not  really  a  benign  condition.  If 
an  apparent  eczema  of  the  nipple,  in  a  woman  over  forty,  fails  to  respond  to 
treatment,  and  becomes  red,  raw,  and  angry,  it  is  almost  certain  that  the  breast 
is  already  cancerous,  though  nothing  can  yet  be  felt.  The  tumour  will  become 
evident,  generally  in  one  to  two  years  ;  but  in  rare  cases  it  may  be  delayed  for 
ten  years.  Fortunately  the  cancer  is  often  of  a  slow  type.  The  prognosis  is, 
therefore,  that  of  scirrhus.  Radium  and  x  rays  will  frequently  ameliorate  the 
eczema,  but  will  not  prevent  the  onset  of  the  cancer.  a  .   Rendle  Short. 

BRIGHT'S  DISEASE.— (See  Nephritis.) 
BRONCHIAL  ASTHMA.— (See  Asthma,  Bronchial.) 

BRONCHIECTASIS.  —  When  bronchiectasis  is  the  sequel  of  measles  or 
whooping-cough  in  childhood,  and  the  dilatation  moderate,  recovery,  often 
complete,  is  probably  the  rule  rather  than  the  exception,  provided  that  death 
does  not  result  owing  to  the  severity  of  the  primary  disease.  The  more  diffuse 
the  bronchiectasis  the  worse  is  the  prognosis,  and  consequently  cases  which  are 


BRONCHI  EC  TA  SIS  1 1 7 

caused  by  pleural  effusion,  collapse  of  the  lung,  and  especially  unresolved 
pneumonia,  usually  run  a  shorter  course  than  those  due  to  chronic  bronchitis. 

The  disease  in  a  few  cases  runs  an  acute  febrile  course  ;  but  in  the  majority 
the  tendency  is  towards  chronicity,  and  instances  are  on  record  in  which 
life  was  prolonged  for  forty  to  fifty  years. 

The  prognosis  in  an  individual  case  is  difficult,  for  it  is  hard  to  estimate  the 
risk  of  the  complications  which  are  usually  associated  with  a  fatal  termination. 
The  more  immediate  modes  of  death  are  marasmus,  bronchopneumonia  with 
septic  absorption,  haemoptysis,  pneumothorax,  gangrene,  tuberculosis,  lardaceous 
disease,  metastatic  abscess  (especially  cerebral  abscess),  and  cardiac  and  renal 
complications.  In  connection  with  this  point,  Lebert's  figures  of  the  effect  of 
the  disease  on  the  general  health  in  80  cases  are  interesting  : — 

Lebert's  80  Cases  Showing   the  Effect    of   Bronchiectasis 
ON  the    General  Health. 


Condition  of  Patient 

No.  of  Cases 

Percentage 

General  good  health               .... 
Slight  but  distinct  disturbance  of  health 
Marked  disturbance  without  compUcation 
Marked  diarrhoea  with  complications  directly  resulting 
from  disease  -               .               -               -               - 
Marked  disturbance  with  accidental  complications 

17 
28 
15 

3 
*17 

21 
35 
18 

3 

21 

"The  complications  were  :  Kenal.  4  ;  heart  disease,  5  ;    cancer  of  other  organs  than  lungs,  4  ;   tuberculosis,  1 ; 
pelTic  abscess,  1 ;  protracted  whooping-cough,  1 ;  chronic  myelitis,  1. 

Lebert  gave  the  following  figures  as  representing  the  duration  of  the  disease 
in  52  cases  :  Under  one  year,  2i'i  per  cent ;  one  to  two  years,  yy  per  cent ;  three 
to  five  years,  30-7  per  cent  ;  six  to  ten  years,  i5"5  per  cent ;  over  ten  years, 
25  per  cent. 

In  an  individual  case,  the  general  nutrition  and  the  amount  of  absorption  of 
bacterial  products,  the  age  of  the  patient,  the  extent  to  which  his  financial  and 
other  circumstances  allow  for  adequate  protection  and  medical  care,  and  the 
presence  of  complications,  must  be  taken  into  account.  If  there  is  little  evidence 
of  absorption  of  bacterial  products,  if  the  patient  is  well  nourished,  and  if  he  can 
be  properly  safeguarded,  the  prognosis  is,  on  the  whole,  towards  chronicity. 
When,  however,  the  complications  previously  mentioned  occur,  and  especially 
when  there  is  septic  absorption,  the  prognosis  is  grave.  The  effect  of  the  absorp- 
tion of  bacterial  products  upon  the  nutrition,  and  hence  the  tendency  to  fatal 
complications,  has  been  diminished  by  the  effective  use  of  creosote  baths.  Again, 
suitable  treatment  by  vaccines,  though  it  does  not  cure  the  disease,  in  some 
instances  does  much  to  diminish  the  septic  character  of  the  expectoration,  and 
may  render  it  odourless.  Further,  vaccine  treatment  appears  not  infrequently 
to  reduce  the  number  of  intercurrent  attacks  of  bronchopneumonia,  pleurisy, 
and  bronchitis,  which  do  so  much  to  undermine  the  patient's  powers  of  resistance. 

In  generalized  bronchiectasis,  surgical  measures  are  of  no  avail.  Favourable 
results  have  been  reported  as  the  result  of  operation  in  cases  in  which  there  is 
a  single  dilatation,  but  in  the  majority  even  of  these  cases  life  is  not  prolonged 
by  surgical  means,  and  in  not  a  few  death  may  come  sooner  as  the  direct  result. 
It  is  possible,  however,  that  better  result?  will  be  obtained  by  more  modern 
methods.  Arthur  Latham. 


INDEX     OF     PROGNOSIS 


BRONCHITIS. 

Acute  Capillary  Bronchitis. — This  condition  is  always  associated  with  some 
bronchopneumonia.  It  rarely  attacks  previously  healthy  persons,  and  is 
especially  fatal  to  young  children  and  old  people.  A  severe  attack  in  an  infant 
may  be  fatal  within  twenty-four  hours  :  an  aged  person  may  succumb  in  a  few 
days. 

In  estimating  the  prognosis,  we  have  to  take  into  account  the  general  surround- 
ings and  previous  health  of  the  patient.  Unfavourable  signs  are  failure  of  either 
the  respiratory,  circulatory,  or  nervous  systems.  Thus  the  outlook  becomes 
grave  if  there  is  urgent  dj'spnoea,  lessening  frequency  of  cough  or  cessation  of 
expectoration  owing  to  feebleness  ;  cyanosis  or  other  signs  of  right  heart  failure  ; 
delirium,  coma,  or  convulsions. 

Acute  Bronchitis  of  the  Larger  Tubes. — In  mild  cases  the  duration  is  as  a  rule 
from  ten  to  fourteen  days,  but  severe  cases  seldom  last  less  than  three  to  four 
weeks.  Recovery  is  always  slow  if  emphysema  is  present.  There  is  a  consider- 
able tendency  towards  relapse,  and  the  precautions  taken  to  avoid  this  have 
much  influence  on  both  the  immediate  and  remote  effects.  The  disease  is  rarely 
fatal,  save  in  young  children  and  old  people,  in  the  acute  asthenic  type,  or  when 
the  disease  is  a  complication  of  nephritis,  heart  disease,  diabetes,  chronic 
bronchitis  associated  \vith  heart  failure,  or  emphysema  ;  but  the  mortality  is 
largely  affected  by  adequate  treatment.  Signs  of  danger  are  :  marked  cyanosis, 
pulsating  veins  in  the  neck,  great  dyspnoea,  short  ineffective  cough  with  cessa- 
tion of  expectoration,  rapid  irregular  pulse,  cold  clammy  skin,  and  a  tendency 
to  sink  down  in  the  bed. 

Chronic  Bronchitis  of  the  Larger  Tubes. — In  young  people  marked  im- 
provement often  occurs,  and  in  a  fair  proportion  of  cases  all  urgent  symptoms 
eventually  disappear.  After  middle  age  there  are  few  recoveries.  This  is 
chiefly  owing  to  the  recurrence  of  acute  attacks  and  the  increase  of  emphj'sema, 
more  especially  when  the  disease  is  dependent  upon  or  associated  with  cardiac 
or  renal  disease.  The  course  of  the  disease  is,  however,  usually  prolonged.  The 
intensity  of  the  symptoms,  and  hence  the  duration  of  the  disease,  are  much 
affected  by  climatic  conditions  and  by  the  amount  of  care  the  patient  can  devote 
to  his  health.  Much  can  be  done  by  medical  treatment,  such  as  vaccine  therapy, 
to  ward  off  acute  attacks  and  to  lessen  the  cough  and  strain  upon  the  heart, 
while  pressure  baths  often  have  a  favourable  influence  upon  the  emphysema. 

Plastic  bronchitis  affords  a  fairly  good  prognosis,  and  patients  have  been  known 
to  live  for  more  than  twenty-five  years  from  the  commencement  of  the  symptoms. 
There  is  a  tendency  towards  the  development  of  ordinarj'-  bronchitis  with  its 
usual  complications,  and  cases  are  recorded  in  which  the  casts  have  led  to 
sufiocation. 

Putrid  bronchitis  if  due  to  simple  catarrh  is  seldom  dangerous  to  life, 
especially  if  appropriate  vaccines  are  used  ;  but  if  due  to  other  causes  is  usually 
fatal.  Arthur  Latham. 

BRONCHOPNEUMONIA. — This  disease  is  always  associated  with  some 
capillary  bronchitis.  The  prognosis  is  grave  in  all  severe  cases,  and  the  mortality 
may  be  as  high  as  30  or  even  50  per  cent.  It  is  greatest  in  3'oung  children,  and 
especially  so  below  one  year  of  age.  In  young  infants,  and  in  rickety  or  badly 
nourished  children  brought  up  under  insanitary  conditions,  the  probabiUty 
of  a  fatal  termination  is  always  considerable.  This  is  especially  true  of  broncho- 
pneumonia complicated  by  whooping-cough.  The  greater  the  extent  of  the 
disease,  the  graver  is  the  outlook.  Primary  cases  have  a  lower  mortaUty  than 
secondary  ones :    thus,  bronchopneumonia  following  bronchitis  has  a  mortality 


BULBAR    PALSY  119 


only  half  as  great  as  bronchopneumonia  following  diphtheria.  The  chief 
immediate  dangers  are  heart  failure,  convulsions,  and  hyperpyrexia  :  that  is 
to  say,  the  amount  of  toxaemia  in  relation  to  the  patient's  strength,  and  the 
extent  of  the  disease,  are  the  determining  factors.  Convulsions  at  the  com- 
mencement of  the  disease  have  not  so  much  significance  as  those  at  a  later 
period.  The  character  of  the  pulse  is  usually  a  better  guide  than  the  rate  of 
breathing ;  a  feeble,  rapid,  and  '  running '  pulse  is  of  graver  significance  than 
rapid  respiration. 

Bronchopneumonia  may  in  a  few  cases  lead  to  enlargement  of  the  bronchial 
glands  to  a  sufficient  extent  to  be  a  source  of  trouble  later  on,  to  bronchiectasis, 
or  to  tuberculosis.  As  a  general  rule,  bronchopneumonia  which  is  an  immediate 
sequel  to  an  acute  infection,  such  as  diphtheria,  is  seldom  if  ever  tuberculous, 
even  though  it  runs  a  prolonged  course  and  gives  rise  to  great  suspicion.  On 
the  other  hand,  a  bronchopneumonia  which  commences  more  or  less  insidiously 
is  often  tuberculous  in  its  origin  and  is  then  nearly  always  fatal. 

It  is  impossible  to  give  the  average  duration  of  the  disease,  as  cases  vary  so 
much  according  to  the  patient's  previous  condition  and  power  of  reaction.  In 
all  cases  there  is  a  great  tendency  towards  relapse,  and  much  care  is  required 
in  convalescence,  especially  with  regard  to  exposure. 

In  my  experience,  the  administration  of  5  c.c.  of  fresh  normal  horse  serum 
by  the  mouth  in  the  early  morning  so  long  as  fever  continues  has  had  a  marked 
effect  in  reducing  the  mortality  of  this  disease.  Arthur  Latham. 

BULBAR  PALSY. — Chronic  bulbar  paralysis  of  nuclear  origin  is,  pathologically, 
the  same  disease  as  progressive  muscular  atrophy  (q.v.),  but  affecting  the  motor 
nuclei  in  the  medulla.  Its  course  is  slow  and  insidious,  and  the  prognosis  is 
always  unfavourable,  most  cases  succumbing  within  a  year,  or  at  most  two  years, 
from  the  onset  of  the  bulbar  symptoms.  Sometimes  the  disease  appears  to  be 
retarded,  or  even,  for  a  few  months,  temporarily  arrested,  by  the  hypodermic 
administration  of  strychnine  in  full  doses. 

Sudden,  so-called  apoplectiform,  bulbar  palsy  is  always  vascular  in  origin  ; 
it  is  generally  due  to  arterial  ob.struction,  and  especially  to  syphilitic  thrombosis. 
Where  the  bulbar  palsy  takes  several  hours,  or  even  a  few  days,  to  develop  (a  less 
common  occurrence),  the  condition  is  dependent  upon  acute  inflammatory 
changes  in  the  medullary  nuclei,  exactly  similar  to  those  which  occur  in  the 
spinal  cord  in  acute  anterior  poliomyelitis.  The  prognosis  as  to  life  in  these  two 
classes  of  bulbar  paralysis  is  relatively  good  if  the  patient  survives  the  acute 
stage,  since  the  lesion  is  not  a  progressive  one.  The  actual  bulbar  symptoms, 
however,  remain  stationary,  for  the  nuclear  disease  is  irreparable. 

Other  cases  of  bulbar  paralysis  are  due  to  infranuclear  and  extramedullar/ 
lesions,  implicating  the  motor  nerves  of  the  bulb  below  their  nuclei  of  origin. 
Such  cases  occur  in  tumours,  and  in  chronic  meningeal  affections,  syphilitic  or 
tuberculous.  The  symptoms  develop  much  more  slowly,  and  are  often  asym- 
metrical, and  even  unilateral,  in  distribution.  Save  in  the  cases  of  syphilitic 
origin,  the  prospects  are  unfavourable. 

In  Pseudo-bulbar  Paralysis,  where  the  patient  has  the  same  difficulty  in  articu- 
lation, deglutition,  and  phonation  as  in  ordinary  bulbar  palsy,  but  without 
atrophy  or  fibrillary  tremor  of  the  affected  muscles,  the  cause  is  entirely  different. 
The  lesion  in  such  a  case  is  a  bilateral  supranuclear  one,  situated  in  the  pyramidal 
tracts.  The  common  history  is  that  of  a  patient  who  has  had  an  ordinary  attack 
of  hemiplegia,  without  bulbar  symptoms  ;  he  may  have  repeated  attacks  of  this 
sort  on  the  same  side,  all  without  the  slightest  bulbar  phenomenon ;  at  last, 
however,  he  has  an   attack  of    hemiplegia,   slight  or   severe,   on  the  opposite 


INDEX     OF     PROGNOSIS 


side;  at  once  bulbar  symptoms  supervene,  articulation  becomes  slurring,  and 
deglutition  becomes  difficult.  The  sequence  of  events  is  so  characteristic,  that 
when  we  meet  with  a  hemiplegic  patient  who  has  pseudo-bulbar  symptoms,  we 
can  confidently  diagnose  a  bilateral  pyramidal  lesion.  The  prognosis  in  pseudo- 
bulbar palsy  is  less  grave,  as  regards  life,  than  in  true  bulbar  palsy ;  since  the 
pseudo-bulbar  symptoms  do  not  tend  to  get  worse,  and  may  even  improve  to  a 
considerable  extent.  The  real  prognosis  depends  on  the  cause  which  has  produced 
the  bilateral  hemiplegia.     {See  Strokes.)  Purves  Stewart. 

BURNS  AND  SCALDS. — A  burn  may  of  course  vary  in  degree  from  the  merest 
trivial  accident  to  an  inevitably  fatal  destruction  of  an  enormous  skin  area ;  but 
there  are  several  points  of  importance  which  may  guide  us  in  prognosis. 

The  Nature  of  the  Burn. — Skin  area,  not  depth,  is  the  determinant  of  the 
prognosis,  except  of  course  in  rare  instances  where  the  abdomen  may  be  opened. 
Thus  a  burn  of  the  sixth  degree  involving  the  foot  and  lower  part  of  the  leg  is 
not  so  dangerous  as  a  widespread  burn  of  the  second  degree  involving  the  trunk 
and  limbs.  Third  degree  burns,  exposing  the  sensitive  papillae  of  the  dermis, 
are  particularly  depressing.  It  is  probably  true  that  burns  of  the  abdomen  are 
the  most  serious. 

If  one  half  of  the  body  surface  is  burnt,  death  is  inevitable  ;  in  the  great 
majority  of  cases,  a  burn  of  one  third  will  also  be  fatal.  In  hospital  practice 
about  a  third  of  the  cases  admitted,  die  ;  this  of  course  varies  with  local  custom, 
pressure  on  the  beds,  etc. 

Influence  of  Age. — Children  and  aged  persons  are  decidedly  the  more  liable 
to  die  from  the  shock  of  a  burn. 

The  Time  Factor. — In  the  majority  of  the  fatal  cases,  death  takes  place  within 
forty-eight  hours  {128  out  of  207  cases — Choyce),  and  no  doubt  most  of  these 
patients  die  from  shock.  Stupor,  shallow  breathing,  prostration,  and  a  quick 
weak  pulse  point  to  a  probable  fatal  termination.  There  is,  however,  a  curious 
group  in  which  symptoms  appear  to  be  due,  not  to  shock,  but  to  some  scorching 
change  in  the  blood.  Such  cases  may,  for  instance,  develop  signs  of  cardiac 
thrombosis  two  or  three  days  after  the  accident,  with  dyspncea,  pain  over  the 
heart,  and  very  irregular  pulse  ;  duodenal  ulcer  is  probably  another  evidence  of 
the  same  blood  changes.  Recurring  vomiting  may  be  due  to  a  similar  cause,  and 
is  of  very  grave  import. 

If  the  patient  survives  the  first  few  days,  the  prospect  of  recovery,  apart  from 
complications,  depends  upon  how  effectually  suppuration  can  be  controlled. 
Pneumonia,  pericarditis,  and  nephritis  appear  to  be  due  in  nearly  every  case  to 
pyaemia  from  suppuration. 

The  Effect  of  Treatment. — There  is  no  doubt  that  careful  treatment  may 
make  all  the  difference  between  life  and  death  in  a  considerable  number  of  the 
cases.  Extensive  lesions  of  the  skin  do  not  produce  shock  in  animals  or  in  man 
under  an  anaesthetic,  and  the  shock  of  a  burn  is  due  principally  to  pain,  and  can 
be  controlled  by  efficient  doses  of  morphia.  The  early  dressings  ought  to  be 
rendered  painless  by  chloroform  or  morphia,  for  this  reason.  Warmth  is  a  very 
important  factor  in  saving  the  patient's  life.  The  blood  changes  are  probably 
beyond  our  control.  The  writer  has  shown  that  in  some  cases  of  severe  burns 
the  specific  gravity  of  the  blood  is  much  raised,  and  the  administration  of  saline 
is  urgently  indicated. 

If  the  burn  is  not  so  extensive  as  to  be  inevitably  fatal,  it  is  well  worth  while 
to  take  particular  care  to  prevent  sepsis  later.  If  the  injured  area  has  been 
fouled,  it  should  be  surgically  cleansed  under  an  anaesthetic.  Reliable  anti- 
septics, like  oil  of  eucalyptus  (i  in  20  in  olive  oil),  improve  the  prognosis,  and  so 


CMCUM,     TUBERCULOUS 


does  a  boracic  bath  applied  for  several  hours  daily ;  but  cases  have  undoubtedly- 
been  lost  by  drug  poisoning.  The  incessant  vomiting  and  dermatitis  of  boric 
acid  poisoning  are  not  as  well  recognized  as  they  should  be. 

Complications. — Pneumonia,  pericarditis,  and  nephritis  can  usually  be  prevented 
by  proper  asepsis.  Duodenal  ulcer  does  undoubtedly  occur,  usually  a  week  or 
ten  days  after  the  burn,  but  it  is  rarer  than  was  formerly  supposed.  Moynihan, 
in  his  classical  study  of  duodenal  ulcer,  was  able  to  find  only  the  merest  hand- 
ful of  authentic  cases.  Out  of  138  deaths  from  burns  at  St.  Bartholomew's 
Hospital,  Lockv/ood  found  only  i  duodenal  ulcer,  with  2  other  cases  showing 
punctiform  haemorrhages.  In  a  few  rare  instances  the  ulcer  has  caused  death 
from  perforation  or  haemorrhage.  These  ulcers  are  probably  due  to  micro- 
scopical embolism  of  the  duodenal  arteries  on  account  of  the  blood  changes, 
followed  by  self-digestion  by  the  juices  of  the  stomach  or  pancreas. 

Tetanus  is  not  very  rare  as  a  complication  of  a  burn,  and  particularly  if  it  is 
earth-infected.  Fourth  of  July  tetanus  following  burns  from  fireworks  is  well 
known  in  America.  Patients  with  earth-infected  burns  ought  probably  to  be 
given  a  prophylactic  dose  of  antitetanic  serum. 

Contraction  with  deformity  is  a  very  distressing  late  complication  of  burns. 
It  only  occurs  if  the  whole  thickness  of  the  skin  is  destroyed.  Something  can 
be  done  to  prevent  it  by  liberal  skin-grafting.  The  writer  has  seen  one  case 
in  which  it  led  to  dislocation  of  the  hip-joint. 

Keloid  and  epithelioma  may  develop  in  the  scar  of  an  old  burn.  X-ray  burns 
appear  to  be  particularly  liable  to  undergo  malignant  changes,  several  members 
of  our  own  profession  having  fallen  victims. 

Scald  of  the  Larynx. — Children  who  have  been  trying  to  drink  from  the  spout 
of  a  kettle  are  liable  to  this  accident.  Unfortunately  there  may  be  no  signs  at 
all,  or  at  most  only  a  little  hoarseness,  for  several  hours,  and  lives  have  been  lost 
by  children  being  sent  away  from  a  hospital  at  this  stage.  A  few  hours  later 
they  are  brought  up  again  with  laryngeal  stridor,  cyanosed,  and  struggling  for 
breath,  when  even  an  immediate  tracheotomy  may  be  too  late  to  save  the 
situation.  With  proper  supervision  and  prompt  interference  if  necessary,  there 
is  no  great  danger.  A.  Rendle  Short- 

CiECUM,  TUBERCULOUS. — This  somewhat  uncommon  disease  is  usually 
diagnosed  as  carcinoma,  forming,  as  it  does,  a  hard  tumour-like  mass  in  the 
caecum.  We  have  not  much  information  as  to  the  natural  course  of  the  com- 
plaint. It  is  customary  to  remove  the  caecum.  The  mortality  after  removal 
by  operation  is  given  as  follows  :  Of  58  cases  in  literature  since  1900,  12  per  cent 
died  (Hartmann)  ;  of  130  other  cases  in  literature,  30  per  cent  died  after  excision, 
and  17  per  cent  after  short-circuiting  (Nikoljski)  ;  of  46  cases  of  four  surgeons 
since  1907,  25  per  cent  died  (Finkelstein).  The  last  figure  is  probably  a  fair 
approximation  to  the  truth. 

If  the  patient  survives  operation,  a  cure  usually  results. 

References. — Finkelstein,  Arch.  f.  klin.  Chir.,  1913,  July,  936  ;  Makins,  Burghard's 
System  of  Operative  Surgery. 

A.  Rendle  Short. 

CALCULI,  PROSTATIC— (See  Prostatic  Calculi.) 


CALCULI,  RENAL.~(5efi  Kidney,  Calculi  of.) 
CALCULI,  VESICAL.— (5ee  Bladder,  Calculi  of.) 
CANCER. — {See  Various  Organs.) 


INDEX     OF     PROGNOSIS 


CANCRUM  ORIS. — This  term  should  not  be  used  for  cases  of  severe 
stomatitis  unless  there  is  black  sloughing  of  the  cheek.  Interpreted  in  this 
way,  the  prognosis  is  very  grave — it  is  given  by  Keen  as  75  per  cent.  Death 
takes  place  within  ten  to  fourteen  days.  Even  if  the  child  recovers,  there  is 
usually  a  horrible  deformity  which  will  require  much  skill  and  many  operations 
to  remedy. 

The  outlook  in  a  particular  case  depends  on  the  extent  of  the  sloughing  and 
on  the  degree  of  toxaemia.  If  the  patient  is  already  worn  out  by  measles  or 
other  illness,  if  there  is  a  poisoned  look,  high  fever,  weak  pulse,  or  coughing, 
death  is  almost  inevitable.  The  best  hope  of  recovery  is  in  a  case  seen  early, 
not  extensive,  promptly  treated,  and  with  little  toxaemia.  a.  Rendle  Short. 

CARBUNCLE. — Although  usually  not  a  dangerous  disease,  it  must  always 
be  borne  in  mind  that  a  large  carbuncle  involves  serious  danger  to  life  when  it 
occurs  in  a  vascular  part,  such  as  the  lip  or  face ;  also  in  elderly,  alcoholic, 
or  broken-down  individuals.  Spreading  in  spite  of  treatment,  delirium,  pyaemic 
abscesses,  or  rigors  all  mean  a  grave  prognosis.  a.  Rendle  Short. 

CARCINOMA. — {See  Various  Organs.) 

CARDIAC  SYPHILIS. — As  this  subject  is  largely  covered  elsewhere  in  this 
volume,  by  articles  on  aortic  valvular  disease,  angina  pectoris,  and  so  on,  a 
short  note  is  added  under  this  heading  merely  to  co-ordinate  the  leading  facts. 

The  effects  of  syphiHs  on  the  heart  and  aorta  are  threefold,  in  that  the  infection 
attacks  the  aortic  wall,  the  aortic  semilunar  valves,  and  the  myocardium  itself 
through  the  medium  of  the  coronary  arteries.  It  is  the  relative  severity  of  its 
attack  on  these  three  several  parts  of  the  circulatory  apparatus  that  determines 
the  prognosis.  When  it  is  the  aorta  that  suffers  most,  and  an  aneurysm  is 
produced,  this  throws  so  powerful  an  extracardiac  bias  into  the  situation  that 
the  whole  outlook  is  practically  conditional  on  the  behaviour  of  the  aneurysmal 
sac.  Usually,  therefore,  when  we  speak  of  the  prognosis  in  cardiac  syphilis, 
it  is  of  the  valvular  and  myocardial  lesions  that  we  are  thinking.  Here  it  may- 
be remarked  that  timely  recollection  of  the  possibility  of  a  syphilitic  element 
in  aortic  regurgitation  and  obscure  cases  of  angina  and  myocardial  weakness, 
will  stimulate  investigation  by  means  of  the  Wassermann  reaction,  searching 
for  signs  of  cerebrospinal  lesions,  and  so  on,  and  the  discovery  of  information 
that  will  be  of  the  utmost  service  for  prognosis  as  well  as  treatment. 

Prognosis  as  to  Life. — The  life  prospects  of  these  patients  have  been  analyzed 
by  Deneke,  of  Hamburg.  He  found  that  about  half  died  within  two  years  of 
the  initial  diagnosis  ;  about  two-thirds  within  three  years  ;  and  about  four-fifths 
within  four  years.  It  is  true  that  these  figures,  dra.wn  from  the  histories  of 
124  patients,  do  not  exclude  cases  of  aortic  aneurysm  ;  but  he  shows  that 
the  outlook  is  only  twice  as  bad  when  there  is  an  aneurysm,  with  or  without 
valvular  incompetence,  as  it  is  in  cases  of  aortitis  without  aneurysm  ;  and 
further,  that  the  prognosis  is  nearly  as  bad  in  cases  of  valvular  insufficiency 
without  aneurysm  as  it  is  when  aneurysm  is  present.  Mitchell  Bruce  found  that 
the  average  expectation  of  life  in  cardiac  syphilis,  from  onset  of  symptoms  to 
death,  was  between  five  and  six  years. 

The  remarkable  proneness  of  these  cases  to  a  sudden  end  is  notorious.  One 
of  the  physicians  at  whose  feet  the  writer  sat  as  a  student  used  to  emphasize  this 
by  telling  stories  of  patients  who  had  died  on  the  doctor's  doorstep,  "  with  a 
gumma  in  the  heart  and  an  iodide  prescription  in  the  pocket."  In  74  fatal  cases 
observed  by  Deneke,  the  end  was  sudden  in  no  less  than  33  (24,  if  deaths  from 


CELLULITIS  123 


bursting  aneurysms  be  excluded).  Of  Mitchell  Bruce's  cases  of  cardio-aortic 
syphilis,  aneurysms  excluded,  50  per  cent  died  suddenly.  This  insecurity  of 
life  is  due  to  the  fact  that,  as  Harlow  Brooks  and  others  have  shown,  gross 
myocardial  lesions  are  to  be  found  in  a  large  majority  of  all  cases  of  cardio-aortic 
syphilis. 

Apart  from  the  development  of  aneurysm,  the  factors  of  danger  in  cardiac 
syphilis  are,  first,  damage  to  the  myocardium,  and  second,  addition  to  its  work 
by  failure  of  the  aortic  valves.  Of  these  the  first  is  clearly  the  more  important 
by  far  ;  so  that  in  seeking  to  form  an  opinion  as  to  the  prospects  in  any  individual 
case,  the  most  important  data  are  those  that  bear  on  the  condition  of  the  cardiac 
muscle. 

The  evidences  of  ventricular  disease  may  be  local  or  diffuse.  The  former 
class  includes  the  signs  of  acute  obstruction  of  a  coronary  artery  or  branch — 
development  of  a  pericardial  rub  following  a  severe  attack  of  precordial  pain 
with  faintness  ;  also  signs  of  gradual  coronary  obstruction,  or  rather  of  its  chief 
result,  formation  of  an  aneurysm  of  the  heart ;  and  heart-block.  Of  these,  the 
two  first  are  the  more  immediately  prophetic  of  sudden  death  ;  and  indeed 
there  is  nothing  of  more  ominous  significance  in  these  cases  than  the  appearance 
of  a  pericardial  rub,  even  where  this  has  been  preceded  by  no  other  evidence  of 
infarction.  Anything  indicative  of  coronary  obstruction  carries  with  it  a  threat 
of  sudden  death.  With  heart-block  it  is  a  little  different,  for  its  appearance  can 
only  endanger  the  patient's  life  if  it  is  accompanied  by  syncopal  or  epileptiform 
attacks.  Although  the  type  of  lesion  conjured  up  in  the  mind  by  the  term 
'  myocardial  syphilis  '  is  focal,  yet  it  must  never  be  forgotten  that  those  same 
focal  lesions  are  merely  the  macroscopic  expression  of  a  widespread  interference 
with  the  nutrition  of  the  heart  muscle  by  disease  of  the  coronary  arteries.  Hence 
we  must  look  out  for  and  correctly  interpret  such  symptoms  as  recurrent 
precordial  pain  on  exertion,  dyspnoea,  puffiness  of  the  ankles,  alternating  pulse  : 
all  these  prove  that  the  ventricular  muscle  is  hard  hit  and  likely  to  give  out  at 
no  distant  date.  One  other  risk  has  to  be  borne  in  mind  in  cases  of  cardiac 
syphilis — that  of  the  development  of  syphilitic  lesions  in  other  vital  organs. 
One  man  recently  under  the  writer's  care  with  aortic  dilatation  and  incom- 
petence, of  luetic  origin,  died  rather  suddenly  of  a  large  cerebral  thrombosis. 
Deneke  found  death  due  to  extracardiac  causes  in  about  20  per  cent  of  his 
fatal  cases. 

As  to  the  result  of  treatment,  Deneke  found  in  his  series  that  thorough  treatment 
with  antisyphilitic  drugs  doubled  the  patient's  expectation  of  life.  The  best 
method  of  treatment  is  still  a  matter  of  some  discussion  ;  from  the  prognostic 
point  of  view  it  may  be  said  that,  as  far  as  is  known,  thorough  treatment  with 
mercury,  either  by  inunction  or  injection,  together  with  iodides,  gives  results 
as  good  as  those  following  the  use  of  salvarsan  ;  while  most  observers  agree  that 
the  latter  plan  introduces  a  considerable  element  of  risk,  at  all  events  in  cases 
where  the  evidences  of  myocardial  invasion  are  at  all  definite.  Even  those 
who  advocate  salvarsan  say  that  repeated  administration  is  essential  and  that 
mercury  should  be  given  as  well  ;  so  that  it  seems  as  if  the  prospect  of  radical 
cure  were  no  brighter  with  this  than  with  the  older  remedies  adequately  employed. 

Carey  F.  Coombs. 

CARIES  OF  THE  SPINE.— (See  Spinal  Caries.) 

CELLULITIS.  —  The  prognosis  in  cellulitis  depends  upon  the  location, 
the  condition  of  the  patient,  and  the  extent  of  the  disease.  Of  889  cases  at 
St.  Bartholomew's  Hospital,  a  good  many  years  ago  when  the  condition  was 
commoner  than  it  is  now,  11  per  cent  died. 


124  INDEX     OF     PROGNOSIS 

Cellulitis  of  the  neck  (angina  ludovici)  is  still  a  very  grave  affection,  if  at 
all  extensive,  on  account  of  the  danger  of  oedema  of  the  glottis  and  pressure  on, 
or  infection  of,  the  air-passages.  Unless  promptly  treated,  it  will  usually  be 
fatal. 

A  cellulitis  of  the  scalp  is  likely  to  cause  fatal  meningitis  in  some  cases  ;  and 
cellulitis  of  the  arm  up  to  the  elbow,  or  of  the  leg  up  to  the  knee,  is  a  grave 
condition.  If  there  is  black  slough,  with  emphysematous  crackling,  death  will 
almost  certainly  take  place.  Other  bad  signs  are  pysemic  abscesses  or  repeated 
rigors,  delirium  at  night,  or  diarrhoea. 

An  aged,  broken  down,  or  alcoholic  person  is  not  likely  to  recover  from  a 
severe  attack  of  cellulitis. 

It  is  very  doubtful  if  antistreptococcic  serum  saves  many  cases  ;  but  proper 
evacuation  of  the  sero-purulent  fluid,  hot  soaking,  and,  if  necessary,  amputation 
of  a  limb  are,  of  course,  life-saving  procedures. 

Stiffness  of  the  tendons  may  be  a  serious  after-trouble  of  cellulitis  of  the  arm. 

A.  Rendu  Short. 

CEREBELLAR     ABSCESS.— (5ee     Intracranial     Complications    of    Ear 
Disease.) 

CEREBRAL  ABSCESS. — {See  Intracranial  Complications  of  Ear  Disease.) 

CEREBRAL     EMBOLISM,     HEMORRHAGE,     AND     THROMBOSIS.— (5ee 

Strokes.) 

CEREBRAL  TUMOUR,  MEDICAL. — [See  also  Cerebral  Tumour,  Surgical.) 
— Once  the  diagnosis  of  intracranial  tumour  has  been  established,  the  prognosis 
must  always  be  extremely  grave.  The  duration  of  life,  however,  varies  within 
the  widest  limits.  Some  patients  die  within  a  few  days  or  weeks  after  the  first 
appearance  of  symptoms,  whilst  others  survive  for  two  or  three  years,  or  even 
for  ten  or  twenty,  though  this  latter  is  uncommon.  The  danger  of  sudden  ter- 
minal coma,  with  death  from  respiratory  paralysis,  has  always  to  be  borne  in 
mind  ;  and  although  this  termination  may  occur  in  tumours  situated  anywhere 
within  the  cranium,  it  is  specially  likely  to  happen  when  the  growth  is  sub- 
tentorial  in  position.  Tumours  of  the  cerebellum,  pons,  and  medulla  are  there- 
fore relatively  more  dangerous  than  those  of  the  cerebrum,  or  those  situated  in 
the  anterior  or  middle  fossa  of  the  cranial  base.  Frontal  tumours  have  the 
longest  survival  period,  as  a  rule.  Sudden  death  may  sometimes  occur  from 
spontaneous  haemorrhage  into  a  soft  gliomatous  tumour,  from  rupture  of  an 
aneurysm,  or  from  a  cysticercus  suddenly  blocking  up  the  aqueduct  of  Sylvius 
or  the  fourth  ventricle. 

In  other  cases,  however,  patients  with  symptoms  of  cerebral  tumour  show  long 
remissions  in  their  symptoms,  or  even  complete  intermissions,  lasting  months 
or  perhaps  years,  during  which  many  of  the  symptoms  clear  up,  ultimately 
returning  again  and  leading  to  a  fatal  termination.  It  is  not  uncommon  for 
single  symptoms,  such  as  vomiting,  visual  troubles,  fits,  etc.,  to  improve  whilst 
the  other  phenomena  persist.  Such  remissions  and  variations  in  the  symptoms 
are  partly  explained  by  changes  in  the  tumour  itself.  Sometimes  a  tumour 
changes  its  main  direction  of  growth,  so  that  parts  of  the  brain  which  were 
originally  directly  compressed  are,  as  it  were,  pushed  aside,  and  are  no  longer 
directly  attacked.  In  other  cases,  the  tumour  undergoes  degenerative  changes  ; 
or  it  may  for  a  time  cease  to  grow.  In  others,  again,  a  cystic  growth  (e.g., 
cysticercus)  may  undergo  absorption  of  its  contents.     In  still  other  cases,  where 


CEREBRAL     TUMOUR.     SURGICAL  125 

a  comparatively  small  growth  obstructs  the  downward  current  of  cerebrospinal 
fluid  through  the  ventricles,  distending  them  and  producing  symptoms  of  severe 
intracranial  pressure, — if  the  growth  slightly  alters  its  position,  the  ventricular 
outflow  is  again  established  and  the  acute  symptoms  subside.  In  some  such 
cases  of  internal  hydrocephalus,  due  to  pressure  from  intracranial  growths,  the 
cerebrospinal  fluid  may  even  find  an  exit  through  the  cribriform  plate  at  the 
root  of  the  nose,  and  produce  a  rhinorrhoea  affording  a  spontaneous  outflow  for 
the  dammed-up  fluid,  with  a  corresponding  improvement  in  the  symptoms. 
If  a  nasal  discharge  of  this  sort  ceases,  the  symptoms  of  intracranial  pressure 
return  at  once. 

Spontaneous  cure  of  intracranial  tumours  is  so  rare  as  to  be  beyond  the  bounds 
of  practical  prognosis.  It  occurs  now  and  then,  however,  in  certain  aneurysms, 
which  become  filled  with  blood-clot  and  then  undergo  obliteration.  In  certain 
parasitic  cysts  (e.g.  cysticercus  and  echinococcus),  the  parasite  may  die  and  the 
cyst  undergo  absorption  or  calcification.  Probably  the  least  uncommon  variety 
of  spontaneous  regression  of  an  intracranial  tumour  is  in  the  case  of  solitary 
tuberculomata,  which  may  undergo  partial  absorption  and  calcification.  Lastly, 
under  the  influence  of  antisyphilitic  remedies,  syphilitic  gummata  may  undergo 
absorption  and  cure,  provided  that  the  syphiloma  is  still  in  the  stage  of  cellular 
proliferation,  and  without  degenerative  or  sclerotic  changes  ;  in  the  latter  case, 
a  gumma  will  resist  even  the  most  energetic  medicinal  treatment. 

Intercurrent  complications,  rather  than  direct  intracranial  pressure  by  the 
tumour  itself,  may  be  the  cause  of  death.  Thus,  respiratory  complications  are 
not  uncommon,  especially  in  the  form  of  inhalation-pneumonia  ;  or  a  patient 
with  a  tuberculoma  may  have  fulminating  meningitis  superadded  ;  or  he  may  die 
from  miUary  tuberculosis.  Purves  Stewart. 

CEREBRAL  TUMOUR,  SURGICAL.— (See  also  Cerebral  Tumour,  Medical). 
— Two  recent  publications  have  thrown  a  great  light  upon  the  end-results  of 
operation  for  this  condition  ;  these  are  the  report  by  Tooth  of  the  figures  for  the 
National  Hospital,  Queen  Square,  and  von  Eiselsberg's  account  of  the  Vienna 
cases. 

Prognosis  apart  from  Operation. — In  the  main,  of  course,  the  outlook  is  very 
gloomy,  and  the  great  majority  of  cases,  after  intolerable  headache,  blindness, 
mental  impairment,  various  forms  of  paralysis,  epilepsy,  etc.,  die  in  the  course 
of  six  months  to  five  years.  But  to  this  generalization  there  are  important 
exceptions.  The  duration,  for  instance,  may  be,  and  often  is,  much  longer  than 
that  described.  Many  cases  are  on  record  in  which  symptoms  of  tumour  lasted 
for  ten  or  more  years.  Tooth,  for  instance,  has  found  amongst  the  patients 
with  cerebral  tumour  discharged  from  the  National  Hospital  in  Queen  Square, 
London,  fifty-one  who  were  not  operated  on,  but  have  survived,  on  an  average, 
about  seven  years.  About  seventy  others  did  not  reply,  and  many  are  pro- 
bably dead.  In  estimating  the  prognosis,  therefore,  the  length  of  time  that 
has  elapsed  since  symptoms  were  first  noticed,  up  to  the  date  of  examination, 
is  very  important. 

The  location  also,  is  important.  Tumours  below  the  tentorium  are  always 
liable  to  cause  sudden  death  by  blocking  the  foramen  magnum.  Many  cere- 
bellar '  tumours  '  in  children  are  tuberculous,  and  may  lead  to  fatal  tuberculous 
meningitis  at  any  time.  On  the  other  hand,  in  adults,  tumours  of  the  cerebello- 
pontine angle  and  of  the  cerebellum  may  be  innocent  ;  and  Tooth  reports  18 
cases  living,  on  an  average,  six  years  after  the  onset  of  symptoms. 

With  reference  to  the  possibility  of  cure,  it  is  of  course  feasible  to  remove  a 
gumma  by  early  and  efficient  treatment  with  mercury  and  iodides  ;   but  there  is 


126  INDEX     OF     PROGNOSIS 

a  tendency  to  relapse,  perhaps  in  some  other  part  of  the  nervous  system,  and 
the  scar  may  lead  to  paralysis,  loss  of  sensation,  or  epilepsy. 

Apart  from  these  cases,  there  are  a  fair  number  of  instances  known  in  which 
symptoms,  apparently  diagnostic  of  cerebral  tumour,  have  ceased  to  advance, 
or  even  more  or  less  completely  disappeared.  Some  of  these  were  probably 
cases  of  serous  meningitis  (Osier),  and  a  similar  confusion  may  arise  in  connection 
with  growths  of  the  spinal  cord. 

The  prognosis  in  individual  cases  must  be  founded  principally  upon  the  rate 
of  progress  of  the  symptoms  up  to  the  time  of  examination,  and  the  diagnosis 
as  to  the  exact  nature  and  location  of  the  growth.  Signs  of  urgency,  calling 
for  operation  if  life  is  to  be  saved  or  made  tolerable,  are  rapidly  increasing 
blindness  or  optic  neuritis,  respiratory  or  cardiac  distress,  drowsiness  or  dullness, 
and  intractable  severe  headache. 

Prognosis  when  treated  by  Operation. — It  is  only  a  minority  of  the  cases 
that  are  suitable  for  any  attempt  at  radical  removal.  Bruns  could  only  attack 
30  out  of  100  cases  seen  by  him,  and  only  three  or  four  of  these  were  permanently 
cured.  At  the  National  Hospital  for  the  Paralyzed  and  Epileptic,  out  of  497 
patients  with  cerebral  tumour,  only  11 1  were  treated  by  removal  of  the  tumour 
(about  a  fifth).  As  both  these  series  would  probably  include  cases  sent  up 
specially  for  operation,  the  proportion  amenable  to  surgical  removal  in  ordinary 
practice  may  be  even  less. 

Operation  Mortality. — Three  operations  have  to  be  considered,  decompression, 
exploration,  and  removal  of  the  tumour. 

Decompression. — The  mortality  of  this  procedure  is  not  negligibly  small. 
In  von  Eiselberg's  series,  6  out  of  28  died  within  a  month  ;  at  Queen  Square, 
29  out  of  80  were  fatal  in  the  same  length  of  time.  The  results  are  usually 
very  satisfactory  in  cases  where  there  is  a  real  rise  of  intracranial  pressure, 
both  in  relieving  headache  and  in  saving  the  sight.  Cerebral  hernia  may 
give  trouble  afterwards  if  the  dura  is  opened.  The  eventual  fatality  from 
the  continued  growth  of  the  tumour  cannot,  of  course,  be  averted,  though 
it  may  be  postponed. 

Exploration. — The  mortality  of  exploration  at  Queen  Square  was  also 
heavy,  25  out  of  74  dying  within  a  month  ;  in  von  Eiselsberg's  series,  16  died 
out  of  35.     The  death-rate,  then,  is  about  40  per  cent. 

Removal  of  the  Growth. — In  the  Queen  Square  series,  31  out  of  iii 
died  within  a  month  ;  and  in  Vienna,  25  out  of  100  ;  so  that  the  mortality 
is  about  25  per  cent.  The  danger  is  least  with  tumours  of  the  cortex, 
and  greatest  with  those  of  the  cerebello-pontine  angle  ;  in  the  latter  case, 
more  than  half  die.  The  causes  of  death  are  shock,  cardiac  or  respiratory 
failure  —  which  may  come  on  a  week  or  two  after  the  operation, —  septic 
meningitis,  and  occasionally  pneumonia.  Most  of  the  extirpations  (all  in 
von  Eiselsberg's  series)  were  done  in  two  stages.  Of  168  cases  at  Vienna, 
17   died   as   a  result  of  the  first   stage. 

End-results. — Turning  next  to  the  end-results  of  operation,  it  will  be  observed 
that  about  a  third  of  the  cases  at  Queen  Square,  treated  by  extirpation  of  the 
growth,  were  alive  and  well  some  months  or  years  afterwards  ;  but  by  no  means 
all  these  were  free  from  danger  of  recurrence.  In  von  Eiselsberg's  series,  of 
t68  cases  operated  on,  only  16  are  described  as  cured,  and  23  as  improved, 
giving  a  total  of  only  about  a  quarter  of  the  whole.  Kuttner's  series  is 
unduly  favourable,  in  that  cases  of  hydrocephalus  and  serous  meningitis  are 
included. 


CEREBRAL     TUMOUR,     SURGICAL 


127 


Results  of  Operation  for  Cerebral  Tumour. 


I. — Tooth's  Series,  National  Hospital  for  Paralyzed  and  Epileptic. 


CaseB 
observed 

AU 
Operations 

Removal 
(partial  or  complete) 

Exploration 

DECOUPItEBSIOH 

Cases 

Per 
cent 

Cases 

Died  in 
am'ntb 

Alive  and 
■«eU* 

Cases 

Died  in 
am'nth 

Cases 

Died  in 
am'nth 

Frontal 
Central 
Temporal     - 
Occipital 
Corona  radiata   - 
Pituitary 
Cerebellum  - 
Extra-cerebellar  - 
Pons     - 
Various 
Not  localized 

96 
66 
47 
14 
13 
14 
74 
44 
41 
49 
40 

70 

54 

30 

7 

6 

4 

33 

36 

4 

18 

3 

73 

83 
64 
50 
46 
28 
44 
82 
10 

7 

31 

30 

7 

2 

1 

4 

11 

24 

1 

9 
1 
1 
0 
1 
1 
4 
13 

1 

13 
9 
4 
0 

0 
0 
4 
t 

17 

14 

14 

3 

2 

0 

14 

1 

1 

7 

1 

5 

4 

1 

0 

1 

5 
1 
1 

7 
0 

22 

10 

9 

2 
3 
0 
8 

11 
3 

10 
2 

7 

2 
5 
0 
1 
0 
2 
7 
0 
5 
0 

Totals  • 

497 

265 

53 

|m 

31 

37 

74 

25 

80 

29 

"'  Alive  and  well  "  includes  some  cases  whera  there  Is  no  recent  report. 


II. —  Von  Eiselsberg's  Series,   Vienna.   (1901-1913). 


Died 

Cases 

End-results 

Location  and 

Within  a 

month 

Later 

Lost 

light 

Re. 

Progress 

Inter- 

Cured 

Better 

No 
better 

currence 

currence 

Extirpation    of 

growth  - 

41 

!l 

10 

— 

1 

9 

6 

3 

3 

Ligature     of 

s 

angeioma 

2 

--- 

— 

— 

0 

1 

0 

1 

H 

Incision  of  cyst 

3 

— 

1 

— 

1 

1 

U 

0 

0 

?^ 

Died     of     first 

stage 
Tumour   not 

6 

— 

— 

— 

— 

— 

— 

— 

found     - 

23 

0 

9 

— 

0 

0 

2 

1 

Pituitary    Body     - 

16 

4 

— 

— 

0 

12 

0 

0 

Extirpation     of 

growth  - 

5 

1 

3 

— 

— 

0 

0 

1 

0 

Incision  of  cyst 

3 

-  - 

— 

— 

.-_ 

3 

0 

0 

0 

~ 

Meningitis 

^H 

serosa    - 

3 

— 

— 

2 

— 

0 

0 

1 

0 

»h 

Died     of     first 

U 

stage 
Tumour  not 

9 

— 

— 

— 

— 

— 

— 

found     - 

12 

7 

— 

3 

— 

0 

2 

0 

0 

2  /Large*       - 

11 

10 

— 

— 

— 

1 

0 

0 

0 

vS     Small* 

4 

1 

— 

— 

— 

2 

0 

0 

1 

"<  i  Died      of    first 

■S  1      stage     - 

2 

— 

— 

— 

— 

— 

— 

— 

— 

'  Larger  or  smaller  than  •  nut. 


INDEX     OF     PROGNOSIS 


III. — Kuttner's  Series  (1907-1912). 

Total  operations,  72  ;  mortality,  30-5  per  cent  ;  tumour  removed  successfully 
in  22  cases.  Of  the  twenty-two  patients,  9  were  alive  three  to  six  months 
after  operation  ;  5,  one  to  two  years  after  ;  4,  two  to  three  years  after  ;  2, 
three  to  four  years  after  ;    and  2,  four  to  five  years  after. 

Functional  results. — Of  22  cases,  10  are  completely  cured  and  back  at  work,  but  only 
4  of  these  were  true  tumours  ;  the  others  were  cases  of  hydrocephalus,  serous  meningitis, 
etc.,  with  symptoms  resembling  tumour.     Sight  was  restored  to  normal  in  75  per  cent. 

It  must  be  remembered,  however,  that  considerable  temporary  relief  is  often 
afforded  to  cases  that  afterwards  recur  and  die.  Innocent  tumours,  of  course, 
give  far  better  end-results  than  the  commoner  sarcomata  and  gliomata,  which 
almost  always  recur.  It  is  very  seldom  that  removal  will  be  successful  if  the 
symptoms  have  progressed  rapidly  before  operation.  Tooth,  on  the  authority 
of  the  Oueen's  Square  results,  advises  that  the  surgeon  should  not  attempt  to 
remove  red  or  purple  diffuse  growths,  probably  glioma  or  sarcoma  ;  nor  yellow 
gelatinous  or  cystic  degenerating  gliomata,  which  become  active  if  interfered 
with.  Nor  should  he  attack  subcortical  swellings,  with  the  exception  that  cysts 
may  be  tapped.  If  the  patient  survives  the  operation,  the  best  results  are 
obtained  in  cases  of  tumours  of  the  cerebello-pontine  angle,  which  are  usually 
innocent.  Allen  Starr  finds  records  in  the  literature  of  69  cases  '  cured  '  (up  to 
three  months)  out  of  162  operated  on  ;  i  was  well  after  twelve  years.  Glioma 
of  the  cortex  is  exceedingly  likely  to  return  ;  only  one  of  the  London  cases  was 
apparently  cured. 

Unfortunately,  after  the  removal  of  tumours  of  the  cortex,  patients  maybe 
left  with  hemiplegia,  aphasia,  or  mental  impairment,  if  the  Rolandic  area  or 
speech  centres  were  involved. 

Summing  up,  we  find  that  only  about  a  fifth  of  the  cases  diagnosed  as  cerebral 
tumour  are  suitable  for  removal  ;  that  a  fourth  of  these  will  probably  die  of  the 
operation  ;  that  another  fourth  will  be  greatly  improved,  or  cured  ;  whilst  the 
remaining  half  will  not  be  improved,  or  will  die  of  recurrence.  Thus,  of  100 
cases,''2o  are  extirpated,  5  die  of  the  operation,  5  are  improved  or  cured. 

Nevertheless,  the  headache  and  loss  of  sight  are  so  distressing,  that  von 
Eiselsberg  quotes  Horsley  with  approval  in  the  dictum  that  "it  is  inhuman 
not  to  operate  on  a  patient  with  cerebral  tumour  "  ;  because  a  decompression, 
at  least,  is  possible. 

References.  —  Tooth,  Rep.  of  XVIIth  Internat.  Med.  Congr.  Sect,  vii.,  202  :  Practi- 
tioner, 1914,  April,  487  ;  Von  Eiselsberg  and  Ranzi,  Archiv.  f.  klin.  Chir.  1913,  Sept. 
309;  Kuttner,  Rev.de  Chir.  1913,  646.  A.  Rendle  Short. 

CERVICAL  RIB. — In  many  cases  cervical  rib  gives  rise  to  no  trouble  at  all ; 
this  must  be  so,  because  though  the  condition  is  usually  bilateral,  the  symptoms 
are  almost  invariably  unilateral.  There  are  three  groups  of  sufferers  ;  those 
with  pressure  on  nerve-roots,  causing  numbness,  pain,  anaesthesia  or  wasting  ; 
those  with  narrowing  of  the  artery,  leading  to  pallor  or  blueness,  and  feeble 
circulation,  or  even  gangrene  ;  and  those  with  a  pulsating  tumour  of  the  neck. 
There  is  said  to  be  a  tendency  to  phthisis,  and  an  aneurysm  of  the  subclavian 
has  been  induced.  There  is  no  tendency  to  spontaneous  cure,  but  some  improve- 
ment may  follow  rest. 

Effects  of  Removal. — There  does  not  appear  to  be  any  mortality,  so  far,  in 
the  recorded  cases.  In  4  out  of  21  operations  collected  by  Eisendrath  the  pleura 
was  accidentally  opened,  and  Thorburn  had  the  same  accident  in  2  out  of  20 
cases ;   but  no  serious  harm  resulted. 


CHLOROSIS  129 

End-results. — These  are  fairly  satisfactory,  but  not  invariably  so.  The  writer 
has  seen  one  patient  who  was  operated  on  three  times  by  various  surgeons  ; 
eventually  she  improved.  Of  the  21  cases  in  Eisendrath's  series,  2  were  no 
better.  Sargent  had  i  failure  in  29  cases.  In  Thorburn's  20  patients,  pain  was 
relieved  in  four-fifths,  and  paralysis  in  half,  of  those  suffering  from  it. 

Streissler  sums  up  the  results  as  follows  :  77  per  cent  are  cured  ;  13  per  cent 
improved  ;  10  per  cent  not  improved.  Sometimes  it  is  several  months  before 
the  benefit  is  felt. 

References. — Thorburn  and  others,  Proc.  Roy.  Soc.  Med.  1913,  vi,  Clinic.  Sect.  113  ; 
Eisendrath,  Amer.  Med.  1904,  viii,  322  ;  Streissler,  Ergebn.  d.  Chir.  u.  Orthop.  1913, 
V.  280.  A.  Rendle  Short. 

CHARCOT'S  JOINTS. — There  is,  of  course,  no  prospect  of  cure  in  these  cases, 
but  with  care  the  joints  may  settle  down  and  remain  in  statu  quo  for  years.  The 
writer  has  seen  some  excellent  results  following  excision  in  suitable  cases. 

A.  Rendle  Short. 

CHICKEN-POX. — This  is  a  disease  which  is  very  rarely  fatal,  and  one  in  which 
complications  but  seldom  occur.  During  the  eleven  months,  February  7,  1902, 
to  January  6,  1903,  25,009  cases  of  chicken-pox  were  notified  in  London.  There 
were,  therefore,  probably  about  27,280  cases  during  the  year  1902.  During 
that  year  32  deaths  from  chicken-pox  were  registered.  Probably  in  not  all  of 
the  cases  was  death  strictly  due  to  that  disease.  But  even  if  it  were,  the 
fatality  was  only  o-ii  per  cent.  Of  some  hundreds  of  cases  which  have  come 
under  my  observation,  I  have  met  with  three  in  which  death  took  place. 
In  one  case,  a  child  of  ten  months,  there  were  laryngeal  symptoms,  presumably 
due  to  vesicles  in  the  larynx,  which  necessitated  tracheotomy ;  the  wound 
became  septic,  and  fatal  bronchopneumonia  supervened.  The  second  case 
was  one  of  varicella  bullosa  in  a  child  aged  one  year.  The  third  was  a  case  of 
so-called  varicella  gangrenosa,  also  in  a  child  aged  one  year.  Varicella 
hsemorrhagica  is  invariably,  and  varicella  bullosa  occasionally,  fatal.  But 
both  of  these  varieties  of  the  disease,  especially  the  former,  are  very  rare. 
Varicella  gangrenosa,  which  is  a  complication  rather  than  a  form  of  the  disease, 
is  more  common,  and  is  occasionally  fatal,  usually  through  some  lung  com- 
plication. The  prognosis  depends  on  the  number  of  pocks  which  become 
gangrenous,  and  the  age  and  physical  condition  of  the  patient.  Should 
the  larynx  be  invaded  by  the  eruption — a  very  rare  event — tracheotomy 
may  be  necessary,  and  this  is  an  operation  which  is  always  attended  by  some 
risk,  as  in  the  case  mentioned  above.  £•.  p^.  Goodall- 

CHLOROSIS. — In  the  average  case  of  chlorosis,  complete  recovery  may 
confidently  be  expected  in  from  six  weeks  to  four  months. 

The  greatest  obstacle  in  the  way  of  absolute  cure  is  failure  of  the  patient  to 
persist  with  the  necessary  treatment.  Symptoms  disappear,  and  the  patient's 
sense  of  well-being  is  so  greatly  increased  that  she  fails  to  realize  that  complete 
health  has  not  been  regained.  It  cannot  be  too  strongly  insisted  upon  that 
the  measure  of  recovery  is  not  the  patient's  subjective  sensations,  or  an  appear- 
ance of  health,  but  an  examination  of  the  blood.  Any  deficiency  in  the  number 
of  corpuscles,  or  percentage  of  haemoglobin,  is  to  be  regarded  as  a  clamant 
indication  for  vigorous  persistence  in  treatment. 

The  reason  for  this  is  the  great  tendency  of  the  disease  to  relapse.  This  may 
occur  after  complete  recovery,  but  the  conditions  which  arise  as  the  result  of 
incomplete  cure  make  relapse  almost  certain.  The  patient  has  little  or  no 
discomfort.      Her    sense    of    well-being   contrasts    strongly    with    her   previous 

9 


I30  INDEX     OF     PROGNOSIS 

breathlessness,  palpitation,  and  headaches.  She  may  now  feel  fit  for  exercise, 
work,  or  recreation  formerly  denied  her.  This  is  indulged  in,  although  her  blood 
is  not  yet  a  satisfactory  medium  for  maintaining  the  respiration  of  the  tissues. 
The  deficiency  can  only  be  met  by  increased  cardiac  and  respiratory  action,  the 
heart  is  strained,  and  in  a  very  short  time  symptoms  become  as  marked  as  ever. 
There  is  now,  however,  this  important  difference ;  they  are  not  nearly  so 
readily  curable. 

Another  result  of  failure  to  attain  complete  recovery  is  that  the  patient  becomes 
accustomed  to  a  condition  of  health  which  is  short  of  the  normal  standard.  She 
becomes  easily  fatigued,  listless,  apathetic,  even  sulky,  and  often  finds  httle 
sympathy  in  her  family  circle.  The  more  striking  symptoms  are  not  so  much 
in  evidence,  and  the  result  may  be  that  the  unfortunate  patient's  disability 
is  attributed  to  an  ungenerous  disposition  of  mind  rather  than  to  a  deficiency 
of  haemoglobin  in  her  blood.  This  type  of  semi-invahdism  is  a  common  result 
of  '  home  '  treatment.  The  occurrence  of  urgent  symptoms  or  marked  pallor 
leads  to  the  purchase  of  a  box  of  Blaud's  pills  or  of  some  proprietary  preparation 
of  iron.  As  soon  as  the  symptoms  have  subsided  or  the  box  has  been  emptied, 
the  treatment,  such  as  it  is,  stops,  and  the  patient  resumes  her  condition  of 
semi-invahdism.  With  increasing  years  this  state  of  affairs  may  be  outgrown, 
but  those  cases  of  chlorosis  in  women  of  thirty  and  even  forty  5'ears  of  age, 
which  are  exceedingly  difficult  to  get  well,  are  mainly  recruited  from  this  class. 

It  may  be  noted  that  in  chronic  chlorosis,  nutrition  is  deficient  at  a  time  of 
life  when  mind  and  body  should  be  most  active.  Girls  doing  mental  work  are 
handicapped,  so  that  they  fail  to  profit  to  the  fuU.  by  education,  and  among 
workers,  chances  of  promotion  may  be  lost  during  the  period  of  life  when  they 
are  most  likely  to  present  themselves.  Over  and  above  all  this,  such  cases  fall 
easy  victims  to  intercurrent  disease. 

Factors  affecting  Prognosis. — 

Age. — If  the  onset  occurs  at  an  early  age,  the  illness  is  more  likely  to  be  severe 
and  prolonged  than  if  the  first  attack  takes  place  at  a  later  age.  It  may  be 
noted  that  chlorosis  practically  never  occurs  for  the  first  time  after  the  age  of 
twenty-three  or  twenty-four,  so  that  when  the  condition  is  met  with  at  a  later 
age,  it  may  safely  be  assumed  that  it  is  a  relapse  or  recurrence  of  a  previous 
attack,  and  that  it  will  be  more  difficult  to  effect  a  complete  cure. 

Heredity. — A  family  history  of  chlorosis  is  not  necessarily  an  indication  of  any 
special  prognostic  significance,  but  if  hereditary  or  family  predisposition  appears 
to  be  a  causal  factor  of  greater  moment  than  stress  of  environment,  then  prognosis 
is  so  much  the  worse. 

Emotional  Conditions. — As  in  other  illnesses,  the  more  definitely  a  removable 
cause  can  be  ascertained,  the  greater  is  the  likelihood  of  cure.  The  difficulty 
is,  that  a  removal  of  the  cause  may  not  be  practicable  or  possible.  An  unhappy 
love  affair  is  proverbially  difficult  for  any  outsider  to  influence,  and  the  most 
tactful  physician  is  the  one  least  likely  to  make  the  attempt  to  do  so.  Home- 
sickness is  another  potent  cause  of  persistence  of  a  chlorotic  condition,  and  its 
removal,  even  when  possible,  may  entail  too  great  a  sacrifice  to  be  entertained 
unless  the  damage  to  health  is  very  persistent  or  severe.  Emotional  con- 
ditions of  many  kinds  may  be  antagonistic  to  the  success  of  treatment,  and 
in  many  instances,  such  as  the  recollection  of  a  severe  fright,  they  may  be  very 
difficult  to  overcome. 

Occupation. — A  sedentary  or  otherwise  unsuitable  occupation  may  be  the  cause 
■of  persistence  of  anaemia,  or  of  relapse  after  cure.  It  is  often  a  difiicult  problem 
for  the  physician  to  advise  in  regard  to  an  occupation  which  may  be  congenial 
and  inimical  to  health  at  the  same  time.     Each  case  has  to  be  judged  on  its  merits. 


CHLOROSIS  131 

The  factors  which  will  have  to  be  balanced  are  the  actual  damage  to  health, 
the  response  to  treatment,  the  probability  of  diminution  of  the  chlorotic  tendency 
as  the  patient  grows  older,  and  the  amount  of  worry,  either  sentimental  or 
financial,  which  a  change  of  occupation  may  entail. 

Locality. — A  change  of  neighbourhood  may  determine  the  onset  of  an 
attack  of  chlorosis.  Curiously  enough  this  effect  sometimes  follows  a  change 
from  town  or  country  to  the  seaside.  Such  cases  readily  yield  to  treatment 
and   speedily  become  acchmatized. 

Marriage. — Chlorosis  very  rarely  persists  after  marriage,  but  occasionally 
does  so.  Such  cases  are  generally  severe.  In  some  instances  there  is  a  complete 
restoration  of  the  blood  to  normal  during  pregnancy,  and  a  relapse  after  the 
puerperium. 

In  dealing  with  chlorosis,  the  ansemia  which  is  often  associated  with  illegitimate 
prep.nancy  should  be  kept  in  mind.  This  anaemia  may  be  true  chlorosis,  but  is 
often  secondary. 

Effect  of  Treatment. — Chlorosis  is  not  one  of  the  diseases  in  which  difi&culties 
arise  through  the  claims  of  alternative  lines  of  treatment.  There  may  be 
difficulties  in  the  way,  but  the  main  indication  is  quite  definite.  That 
indication  is  the  adequate  administration  of  iron.  The  difficulties  which 
may  arise  are  the  persistence  of  faulty  conditions  of  life,  or  a  disinclination  or 
disability  of  the  patient  to  take  a  satisfactory  dietary, — carbohydrates,  largely 
in  the  form  of  biscuits  and  sweets,  being  preferred  to  meat. 

In  the  severer  cases,  a  speedy  restoration  in  health  cannot  be  expected  unless 
the  patient  is  confined  to  bed.  It  is  our  practice  to  advise  every  case  with  less 
than  60  per  cent  of  haemoglobin  to  stay  in  bed  till  the  percentage  is  well  above 
that  figure,  and  if  we  are  asked  how  long  the  patient  will  be  kept  there,  we  may 
say  three  weeks.  That  period  may  be  extended  or  shortened  as  the  result  of 
blood  examination,  but  it  is  a  fair  average.  Even  the  milder  cases  mend  more 
rapidly  in  bed  than  when  they  are  going  about.  Amelioration  may  be  seriously 
delayed  by  the  patient's  inability  to  retain  iron.  Such  cases  are  not  common, 
especially  if  rest  in  bed  be  insisted  on. 

Dyspepsia  and  constipation,  when  they  are  met  with,  may  have  to  be  treated 
before  any  iron  therapy  can  be  persisted  in,  and  the  time  of  cure  is  of  course 
postponed.  Very  rarely,  even  when  dyspeptic  symptoms  have  been  removed, 
iron  is  not  well  borne,  and  we  may  be  obliged  to  fall  back  on  one  of  the  less 
irritating  forms,  such  as  the  scale  preparations,  or  one  of  the  organic  combinations. 
Neither  will  be  found  nearly  so  efficacious  as  the  perchloride,  carbonate,  or 
reduced  iron.  Many  of  the  organic  preparations  are  useless;  preparations  of 
haemoglobin  are  notably  valueless,  and  considering  the  minute  traces  of  iron 
which  they  contain,  this  is  not  surprising.  The  great  drawback  to  all  organic 
compounds  is  their  small  proportion  of  iron,  and  their  expense. 

Not  much  is  gained  as  a  rule  by  the  addition  of  strychnine  and  other  drugs 
to  the  prescription,  unless  there  is  some  special  indication  for  them.  A  little 
arsenic  may  be  of  use,  when  the  count  of  red  corpuscles  is  very  low.  When 
a  case  is  complicated  by  considerable  atony  or  dilatation  of  the  heart,  appropriate 
treatment  is  of  course  called  for,  and  the  question  of  prognosis  then  enters  a 
somewhat  wider  sphere.  We  may  remark,  however,  that  cardiac  atony  or 
dilatation,  due  to  chlorosis,  is  in  nearly  every  case  a  readily  curable  condition. 

The  idea  that  chlorosis  depends  on  constipation  is  now  exploded.  Certain  it 
is  that  chlorosis  is  not  cured  by  purgatives,  although  they  may  play  a  useful 
part  in  its  treatment. 

The  view  of  Haldane  and  Lorrain  Smith,  that  chlorosis  is  due  to  an  increase 
of  blood  plasma,  has  led  to  a  trial  of  therapeutic  measures  intended  to  deplete 


132  INDEX     OF     PROGNOSIS 

the  body  fluids.  Purgatives,  diuretics,  diaphoretics,  and  hot  baths  have  been 
tried,  but  without  good  result,  and  the  physician  has  been  glad  to  fall  back  on 
treatment  by  iron.  Attempts  to  influence  chlorosis  by  bleeding,  with  the  view 
of  thereby  stimulating  the  bone-marrow,  have  been  made,  but  the  results  have 
not  been  satisfactory. 

It  may  be  stated  that  when  such  measures  are  tried  alone  they  fail,  and  when 
they  are  tried  along  with  the  administration  of  iron,  the  ensuing  benefit  is 
attributable  to  the  iron. 

When  iron  is  reasonably  well  tolerated  and  fails  to  cure  anaemia,  we  may  be 
assured  that  in  99  per  cent  of  cases  the  anaemia  is  not  chlorosis,  and  a  revision 
of  diagnosis  is  called  for.  Rheumatism,  syphilis,  and  tuberculosis  are  among 
the  most  likely  causes  of  confusion. 

Complications. — -Any  anxiety  that  is  ever  occasioned  by  a  case  of  chlorosis 
is  much  more  likely  to  be  due  to  the  occurrence  of  a  complication  than  to 
the  disease  itself.  A  connection  between  chlorosis  and  gastric  ulcer  is  well 
recognized,  but  their  exact  relationship  cannot  be  said  to  be  well  defined. 
A  history  of  chlorosis  in  gastric  ulcer  is  exceedingly  common,  and  we  have  seen 
the  symptoms  of  gastric  ulcer  arise  in  cases  of  chlorosis  under  actual  observation. 

The  occurrence  of  one  or  more  of  the  symptoms  of  exophthalmic  goitre  during 
the  course  of  chlorosis  is  probably  too  frequent  to  be  a  mere  coincidence. 
Out  of  a  series  of  255  cases  of  chlorosis,  quoted  by  von  Noorden,  34  showed 
more  than  one  of  the  symptoms  of  Graves's  disease. 

The  complication  of  outstanding  importance  in  connection  with  chlorosis  is 
venous  thrombosis.  It  occurred  in  6  out  of  431  cases  reported  by  von  Erben, 
and  in  5  out  of  230  of  von  Noorden's  histories.  The  thrombosis  may  occur  in 
the  femoral  veins  or  in  the  arms,  but  unfortunately  one  of  the  commonest  sites 
is  in  the  cerebral  sinuses.  The  occurrence  of  the  latter  is  an  experience  not 
readily  forgotten  by  the  medical  attendant.  It  is  one  of  the  catastrophes  of 
medicine,  and  there  is  the  danger  that  the  symptoms  may  at  first  be  attributed 
to  hysteria.  Nearly  all  post-mortem  records  of  cases  of  chlorosis  give  venous 
thrombosis  as  the  cause  of  death. 

Intercurrent  Affections. — An  important  aspect  of  chlorosis  is  that  it  increases 
liability  to  all  forms  of  infectious  disease,  and  diminishes  the  patient's  powers 
of  resistance  to  them.  G.  L.  Gulland. 

A.  Goodall. 

CHOLECYSTITIS. — Cholecystitis  may  be  diagnosed  under  the  following 
circumstances  : — 

Acute  Suppurative  Cholecystitis. — This  may  occur  in  connection  with  gall- 
stones {vide  infra),  as  a  sequel  of  typhoid  fever,  or  apart  from  any  known  cause. 

In  the  post-typhoid  cases,  there  are  reports  in  the  literature  of  21  operations 
with  8  recoveries.  Idiopathic  cases  are  rare,  and  simulate  appendicitis.  The 
prognosis  depends  entirely  on  early  diagnosis  and  operation  ;  granted  this, 
the  majority  recover;    otherwise  nearly  all  die. 

Cholecystitis  without  Gall-stones,  but  causing  Similar  Symptoms. — This 
is  by  no  means  rare,  and  many  of  the  patients  are  operated  on  and  drained  under 
the  mistaken  supposition  that  stones  will  be  found.  According  to  Stanton, 
of  98  such  cases  46  were  cured,  10  much  better,  23  rather  better,  and  19  no 
better.     These  results  are  not  nearly  as  good  as  in  ordinary  gall-stone  cases. 

Empyema  of  the  Gall-bladder. — This  is  usually  due  to  impaction  of  a  stone 
in  the  cystic  duct,  followed  by  infection.  If  an  operation  is  performed  early, 
the  great  majority  do  well  after  cholecystectomy. 

Cholecystitis  with  Gall-stones. — (See  article  on  Gall-stones.)  Septic 
infection   greatly  increases  the  risk  of  the  operation  for  gall-stones  ;    at  the 


CHOREA  133 

Bristol  Royal  Infirmary  2  out  of  9  such  cases  died,  and    in  the  Mayos'  series 
10  out  of  61.     The  end-results  are  also  less  satisfactory. 

References. — Stanton,  Joiir.  Amer.  Med.  Assoc.  1911,  Ivii,  441  ;  Mayo,  Ann.  Surg. 
1906,  xliv,  209;    Rendle  Short,  Bristol  Med.-Chir,  Jour.  1913,  March,  34. 

A .  Rendle  Short. 
CHOLELITHIASIS.— (See  Gall-stones.) 

CHOLERA. — There  is  always  a  large  mortality — over  50  per  cent — in  the 
epidemics  in  Europe.  It  is  less  towards  the  end  of  an  epidemic,  but  during 
the  height  thereof  it  is  greater,  sometimes  much  greater.  '■ 

Rogers  believes  that  a  reduction  in  the  mortality  may  be  expected  by  the  use 
of  hypertonic  saline  injections  and  permanganates  by  the  mouth.  Out  of 
133  cases,  he  treated  39  in  this  manner  with  9  deaths,  or  23-1  per  cent ;  whilst 
in  94  not  so  treated  there  were  59  deaths,  or  62-7  per  cent.  c.  W.  Daniels. 

CHOREA. — Prognosis  is  mainly  concerned  with  childhood,  although  the 
occurrence  of  chorea  in  adolescence  and  in  adult  life  is  thoroughly  recognized. 

It  is  interesting  to  notice  in  an  out-patient  department  the  manifestations  that 
rheumatic  children  show  when  they  are  first  brought  to  a  hospital,  and  the  result 
gives  a  rough  practical  idea  of  the  relative  frequency  of  the  important  ones. 

Thus  in  500  cases,  248  suffered  from  arthritis  and  arthritic  pains,  350  from 
morbus  cordis,  245  from  chorea,  137  from  sore  throat,  and  39  showed  nodules. 

It  should  be  added  that  all  cases  of  chorea  were  looked  upon  as  rheumatic, 
an  error  probably  on  the  safe  side. 

Chorea  is  much  more  frequent  in  the  female  ;  of  284  consecutive  cases,  202 
were  females  and  82  were  males. 

This  manifestation  is  very  seldom  directly  fatal  in  childhood.  Of  the  many 
hundreds  that  the  writer  has  seen,  only  2  have  died  from  the  severity  of  the 
movements,  though  some  others  have  been  desperately  ill.  So  far,  then,  as  the 
first  problem  in  prognosis — the  outlook  for  the  particular  attack — we  may  with 
confidence  feel  that  it  is  good — a  warning,  let  it  be  added,  not  to  over-drug 
these  patients. 

The  duration  of  an  attack  is  most  uncertain.  We  may  collect  statistics  and 
arrive  at  some  such  average  time  as  six  to  eight  weeks,  but  to  apply  any  average 
to  a  particular  case  is  as  likely  as  not  to  result  in  failure. 

The  liability  to  relapse  is  great,  and  there  is  a  group  of  cases  which  seems  to 
develop  annually  a  fresh  attack  over  a  period  of  years.  Of  special  interest  is 
the  fact  that  these  attacks  seem  to  come  on  almost  spontaneously.  With  regard 
to  this  entire  question  of  recurrence  in  rheumatism,  it  is  remarkable  how  persis- 
tently an  obvious  event  is  demanded  as  an  explanation  for  the  occurrence ;  yet 
who  of  us,  with  patients  suffering  from  tuberculosis,  would  expect  to  find  a 
clear-cut  explanation  for  every  lighting  up  of  that  infection  ?  Why  should  not 
also  the  rheumatic  infection  lie  dormant  in  the  system,  as  undoubtedly  the 
tubercle  bacillus  does,  and  light  up  again  under  circumstances  of  climate  and 
season  which  we  cannot  definitely  ascertain  ? 

The  prognosis  of  chorea  is  intimately  bound  up  with  that  of  heart  disease, 
for  217  consecutive  cases  showed  obvious  signs  of  organic  heart  disease  in  122. 
Two  points    will,  however,  be  emphasized  here. 

Firstly,  that  recurrent  chorea  should  always  put  us  on  guard  for  the  develop- 
ment of  mitral  stenosis  ;  secondly,  that  this  manifestation,  if  severe,  is  a  very 
grave  event  when  there  is  also  severe  carditis. 

When  severe  chorea  develops  at  the  height  of  a  pericarditis,  a  fatal  issue  is 
frequent.  In  20  fatal  cases  of  acute  cardiac  rheumatism  in  which  chorea  was 
a  prominent  symptom,  14  died  in  their  first  attack,  and  in  every  case  there  was 


134  INDEX     OF     PROGNOSIS 

pericarditis.  Conversely,  when,  during  a  severe  chorea,  acute  carditis  develops, 
the  prognosis  is  always  grave. 

There  are  some  cases  of  chorea  in  which  perfect  recovery  is  extremely  slow, 
and  it  is  doubtful  whether,  for  some  years,  the  child  can  be  really  said  to  be  quite 
natural  in  its  movements.  Such  cases  may  have  exacerbations  once  or  twice 
each  year,  and  may  be  called  examples  of  chronic  chorea.  Eventually  they 
appear  to  get  well,  although  the  improvement  is  so  gradual  that  it  is  difficult 
to  define  when  the  recovery  occurs. 

The  mental  condition  in  some  of  these  cases  is  considerably  altered,  and  the 
writer  has  known  several  of  them  looked  upon  as  mentally  deficient.  Children 
with  chorea  are  often  exceedingly  unstable  and  emotional  long  after  the  move- 
ments have  disappeared,  and  if  in  addition  there  has  been  practically  no  education, 
there  is  no  doubt  that  the  standard  of  intelligence  in  the  most  chronic  cases  is 
much  lowered,  and  very  possibly  permanently  damaged.  As  a  rule,  in  ordinary 
cases,  the  intelligence  is  good,  although  the  mental  balance  is  always  weak  in 
the  children  who  are  the  victims  of  severe  chorea. 

We  must  remember  that  there  are  rare  cases  of  tuberculous  meningitis  in 
which  movements  indistinguishable  from  rheumatic  chorea  occur  ;  the  prognosis 
in  such  is,  of  course,  hopeless. 

Mental  delusions  and  hallucinations  that  occur  in  some  cases  pass  away,  as 
does  also  dumbness. 

In  adult  life,  the  predominance  of  chorea  in  the  female  still  holds  good,  and 
the  disease  is  more  severe  and  certainly  more  fatal,  although  such  an  event 
is  decidedly  rare.  The  Guy's  records  quoted  by  Herbert  French  showed  3  deaths 
in  29  consecutive  cases,  a  much  higher  proportion  than  occurs  in  childhood. 
The  mental  changes  in  the  adult  are  likely  to  be  more  prominent  than  in  the 
child,  and  may  result  in  an  actual  dementia  lasting  for  a  considerable  time,  and 
some  of  these  patients  are  indeed  very  close  to  the  border  of  insanity. 

It  must  be  remembered  that  chorea  may  sometimes  begin  at  a  very  early  age. 
The  writer  has  had  3  cases  in  which  the  condition  developed  under  three  years 
of  age.  In  all  the  very  young  cases  he  has  seen  there  has  also  been  cardiac 
disease,  a  point  of  great  prognostic  importance. 

The  duration  of  an  attack  depends  to  some  extent  upon  the  mode  of  onset. 
The  most  acute  cases  in  childhood  often  recover  the  most  quickly ;  the  more 
chronic  ones  may  linger  on  for  months. 

Do  any  drugs  alter  the  prognosis  ?  That  careful  and  rational  treatment 
improves  the  outlook  is  undoubted,  but  there  seems  no  one  drug  that  has  yet 
been  discovered  which  produces  a  certain  curative  action.  On  the  other  hand, 
the  prognosis  may  be  made  much  less  favourable  by  reckless  treatment.  Severe 
arsenical  neuritis  is  a  terrible  addition  to  the  burden  of  the  illness  ;  salicylate 
poisoning,  or  death  from  overdosage  with  chloral,  are  tragic  events,  but  not 
unknown  happenings.  Chloretone  may  produce  alarming  symptoms  in  child- 
hood if  given  incautiously,  but  the  intoxication  is  a  passing  one,  and  to  this 
extent  has  little  effect  upon  the  prognosis. 

So  far  as  the  writer  can  ascertain,  a  good  deal  will  depend  in  the  question  of 
prognosis  upon  the  adaptation  of  the  line  of  treatment  to  the  individual  and  to 
the  phase  of  the  illness.  Exceedingly  severe  physical  and  emotional  storms 
if  treated  with  arsenic  will  not  derive  benefit,  but  are  assisted  by  nerve  sedatives. 
A  combination  of  the  salicylates  and  bromides  seems  helpful  to  early  rheumatic 
cases.  Arsenic  aids  recovery  when  the  temperature  is  normal,  but  the  nervous 
system  is  obstinately  unstable.  Rest  and  absolute  quiet — indispensable  in  the 
early  stages — are  often,  towards  the  end  of  a  long  case,  much  inferior  to  cheerful, 
sensible  company,  and  orderly  exercises.  F.  /.  Poynton. 


CLEFT    PALATE  135 


CHORION- EPITHELIOMA.  —  No  type  of  malignant  disease  is  found  to 
present  more  marked  variation  in  respect  of  its  malignancy.  On  the  one  hand, 
death  has  followed  growth  and  the  performance  of  radical  operation  within 
the  month  ;  while  on  the  other  hand,  in  some  cases  where  operation  has  been 
delayed  for  more  than  a  year  after  symptoms  indicative  of  malignancy  have 
occurred,  yet  the  patient  has  been  saved.  Even  when  metastases  have  been 
left  behind  at  the  time  of  operation,  recovery  has  taken  place  in  a  few  cases. 
Cases  are  recorded  in  which  spontaneous  cure  has  occurred — where  the  diagnosis 
has  rested  upon  the  presence  of  vaginal  nodules  and  masses  of  growth  in  the 
urethral  veins,  which  have  been  subjected  to  microscopical  examination. 

There  is  some  evidence  which  suggests  that  cases  following  vesicular  mole  are 
less  virulent  than  other  forms.  As  the  presence  of  hydatid  mole  has  in  many 
instances  acted  as  a  danger  signal,  it  is  likely  that  an  ensuing  chorion-epithelioma 
will  be  attacked  at  an  earlier  stage  than  a  growth  following  upon  normal  preg- 
nancy or  abortion.  Further,  the  extreme  difficulty  of  deciding  when  a  hydatid 
mole  has  taken  on  a  malignant  character  will  often  lead  to  radical  operation 
earlier  than  absolutely  necessary.  All  investigators  are  agreed  as  to  the 
impossibility  of  deciding  in  borderline  cases,  and  clinical  observation  and 
symptoms  must  be  considered  in  forming  an  opinion. 

Teacher^  gives  the  following  results  in  cases  collected  by  him  in  the  literature  : 
Of  99  cases  operated  on,  ii-i  per  cent  died  within  a  few  days.  Of  63  cases 
operated  on,  13,  or  20-6  per  cent,  were  in  good  health  and  free  from  recurrence 
two  years  later.  Two  years  may  safely  be  taken  as  indicating  a  complete  cure 
in  these  cases. 

Sepsis,  or  general  dissemination,  is  the  final  stage  in  the  disease  ;  but  cases 
which  were  known  to  have  had  abdominal  metastases  and  later  to  have  had 
haemoptysis,  suggesting  the  presence  of  deposits  in  the  lungs,  have  yet  in  rare 
instances  been  recorded  as  recovering. 

Chorion-epithelioma  of  the  Fallopian  Tube. — The  cases  which  appear  to 
have  originated  in  the  Fallopian  tube  are,  as  might  be  expected,  more  serious 
than  in  the  case  of  the  uterus.  In  the  first  place  the  difficulty,  almost  the 
impossibility,  of  diagnosis,  and  in  the  next  place  the  early  dissemination  which 
occurs,  both  militate  against  a  favourable  outlook. 

Bazy2  has  collected  12  cases,  with  the  following  results  :  2,  not  operated  on, 
died  ;  of  the  other  10,  who  were  operated  on,  5  died  soon  after  operation,  4  lived 
from  two  to  four  months,  i  was  cured.  In  one  case  the  growth  was  only  the 
size  of  an  early  tubal  gestation,  for  which  indeed  it  was  mistaken  at  the  time 
of  operation ;  nevertheless  the  patient  died  in  a  few  weeks  with  extensive 
metastases.  In  contrast  to  this  is  a  case  recorded  by  Phillips,^  who  removed 
a  chorion-epithelioma  of  the  left  tube,  and  later  operated  for  metastases, 
removing  the  uterus  and  right  appendage,  but  leaving  behind  a  mass  at  the 
root  of  the  mesentery  which  he  took  to  be  metastases  in  glands  ;  yet  the 
patient  recovered  and  was  well  two  and  a  half  years  later. 

References. — '^Allbutt's  System  of  GyncBCology ,  1909,  407  ;  "Ann.  de  Gyn.  et  d'Obsi. 
1913,  April ;  ^Jour.  Obst.  and  Gyn.  1911,  ii,  299.  Bryden  Glendining. 

CIRRHOSIS.— (5ee  Liver.) 

CLEFT  PALATE. — In  spite  of  the  publication  of  some  very  important  series 
of  cases,  well  followed  through  and  treated  by  various  methods,  we  are  still 
without  reliable  information  on  some  necessary  points.  It  would  be  very 
valuable,  for  instance,  to  have  data  for  judging  the  mortality  amongst  cleft 
palate  babies  in  the   early  years   of   life,  before  the  age  at  which  it  has  been 


136 


INDEX     OF     PROGNOSIS 


customary  to  operate.  Sir  Arbuthnot  Lane  claims  that  many  lives  are  saved  by 
closing  the  palate  during  the  first  few  weeks  after  birth,  because  so  many  of  these 
children  would  otherwise  die,  but  this  opinion  is  unsupported  by  figures  and  is 
open  to  grave  doubt. 

Further,  we  do  not  know  whether  children,  whose  palates  have  been  closed  by 
a  flap-operation,  will  eventually  be  able  to  speak  well.  At  the  exhibition  of  cases 
treated  by  various  methods  at  the  Royal  Society  of  Medicine  in  191 1,  very  few 
of  those  shown  by  the  advocates  of  this  procedure  were  old  enough  to  talk,  and 
their  mouths  showed  a  good  deal  of  scarring  in  many  cases,  so  that  it  was  open 
to  question  if  the  very  essential  mobility  of  the  soft  palate  would  be  obtained. 

On  other  points,  however,  we  are  now  in  possession  of  very  excellent  data. 
Four  methods  of  treatment  come  up  for  discussion  ;  (i)  Langenbeck' s ,  or  the 
ordinary  operation  ;  (2)  Lane's  turn-over  flap  method  ;  (3)  Brophy's  operation  ; 
and  (4)  the  Obturator  method. 

I.  Langenbeck's  Operation. — Provided  that  care  is  exercised  in  the  choice  of 
time  of  operation,  so  that  the  child  is  in  good  health  when  it  is  performed,  the 
immediate  danger  to  life,  in  patients  two  years  of  age  or  older,  is  extremely 
small.     Berry  reports  154  cases  without  a  death. 

The  prospect  of  closure  of  the  gap  is  good.  Berry  says  that  he  has  never  seen 
a  cleft  which  could  not  be  closed  by  operation,  provided  that  the  parts  had  not 
been  spoiled  by  a  previous  failure.  In  his  list  of  138  first  operations,  there  were 
109  in  which  complete  union  took  place,  or  the  hole  left  was  only  big  enough  to 
admit  a  probe  and  would  probably  close  spontaneously.  In  25  cases  success 
was  partial  or  a  hole  remained  ;  some  of  these  were  cured  by  a  second  operation. 
In  4  cases  there  was  complete  failure  ;  some  of  these  also  were  remedied  sub- 
sequently. 

Second  operations  gave  13  successes  and  3  partial  successes. 

The  end-results  as  regards  speech  depend  on  many  factors :  the  age  at  operation, 
the  length  and  mobility  of  the  soft  palate,  the  intelligence  of  the  child,  and  the 
care  in  after -training.  In  Berry's  tables,  the  speech  was  investigated  at  least 
a  year  later  in  97  cases ;  it  is  described  as  good  in  36,  good,  but  certain  letters 
still  gave  trouble,  in  21,  and  fair  or  poor  in  40  ;  in  many  of  these  last  there 
was  very  definite  improvement,  others  were  mentally  defective,  and  the  great 
majority  had  no  proper  training. 

The  end-results  of  second  operations  were  not  so  good  ;  out  of  13  followed, 
3  spoke  well,  3  had  trouble  with  certain  letters,  and  7  were  only  moderately 
improved. 

Langenbeck's  Operation  (Berry). 


Cases 

IJeatbs 

0 
0 

Union                        | 

Speech 

Complete  or 
virtually  com- 
plete 

Partial 

Failure 

Good 

Fairly 
yood 

Fair 

First  operations    - 
Second  operations 

138 
16 

109 
13 

25 
3 

4 
0 

36 
3 

21 
3 

40 

7 

2.  Lane's  Flap  Operation. — At  the  meeting  of  the  Royal  Society  of  Medicine 
in  191 1,  the  principal  exponents  of  this  method  were  Sir  Arbuthnot  Lane,  Hilton 
Fagge,  and  one  of  the  former's  house  surgeons. 

Of  Lane's  operations,  369  were  reported,  with  a  mortality  of  about  6  per  cent. 
Of  these,  144  were  first  operations  on  children  under  twelve  months,  the  majority 
being  but  a  few  weeks  old.     By  this  very  early  interference,  such  is  the  argument, 


COLITIS 


137 


shock  is  avoided,  ill-development  of  the  mouth  and  nasopharynx  prevented,  and 
children  are  saved  who  would  otherwise  die  of  malnutrition.  Of  these  144  cases, 
18  (12-5  per  cent)  died  in  hospital.  What  eventually  happened  to  the  survivors 
is  not,  as  a  rule,  known. 

Fagge  reported  57  cases,  of  which  38  were  under  one  year  old.  Of  these,  3 
died  in  hospital,  and  an  attempt  to  follow  up  the  others  showed  that  14  had  died 
since.  It  is,  therefore,  by  no  means  certain  that  the  operation  is  life-saving  ; 
probably  the  reverse  is  the  truth. 

Goyder  has  operated  on  30  cases,  all  but  3  by  Lane's  method.  He  failed  to 
obtain  complete  closure  at  the  primary  operation  in  7  cases. 

The  end-results  as  regards  speech  are  not  known  in  a  sufficient  number  of  cases 
to  justify  deductions.  In  15  cases  investigated  by  Goyder,  speech  was  good  in 
4,  fair  in  4,  and  poor  in  7.  Three  of  the  4  classed  as  good  were  still  very  young, 
and  the  final  condition  remains  to  be  seen. 

Flap  Operation. 


Lane,  all  cases 

,,      first  operations — 
under  one  year  old 
Fagge,  all  cases  - 

„      first  operations — 
under  one  year  old 


369 

144 

57 

38 


Deaths  in  Hospital 


22  (=5-9  per  cent) 
18  (=12-5  per  cent) 

3  (=7'8  per  cent) 


Died  subsequently 


14  (=37  per  cent) 


3.  Brophy's  Operation. — The  essential  point  in  this  operation  is  to  force  the 
maxillae  together  by  stout  wires  before  the  child  is  three  months  old.  By  this 
means  it  is  usually  possible  to  close  a  wide  gap,  the  best  results  being  obtained 
Avithin  a  few  weeks  of  birth.  Brophy  claims  to  have  treated  300  cases,  with  a 
mortality  of  only  3  per  cent,  but  5  out  of  11  English  cases  died,  and  necrosis 
ensued  in  another.  This  operation  can  only  be  used  when  there  is  a  complete 
cleft  of  the  hard  palate. 

Ulrich  uses  a  somewhat  similar  method.     He  lost  2  out  of  10  cases. 

4.  The  Obturator. — It  is  easy  to  close  the  cleft  in  the  hard  palate  by  this  means, 
but  it  is  difficult  or  impossible  to  provide  a  movable  soft  palate  controllable  by 
muscles,  and  therefore  speech  is  not  greatly  improved.  The  obturator  is  more 
useful  in  adults  than  in  young  children,  who  would  require  frequent  changes, 
and  might  also  get  it  impacted  in  the  oesophagus. 

References. — Berry  and  Legg,  Hare  Lip  and  Cleft  Palate,  1912  ;  Proc.  Roy.  Soc. 
Med.  1911,  iv,  pt.  3,  surgical  section,  169  ;  Goyder,  Brit.  Jour  Surg.  1913-14,  i,  259. 

A.  Rendle  Short. 
CLUB  FOOT.— (See  Talipes.) 


COLITIS.— 

Simple. — The  prognosis  is,  as  a  rule,  good,  provided  the  condition  is  taken 
i  n  hand  early.  When  very  exceptionally  acute,  death  may  occur  from  exhaus- 
tion, toxcEmia,  or  collapse. 

Membranous. — This  disease  is,  as  a  rule,  chronic  ;  however,  the  majority 
of  patients  eventually  recover,  though  some  do  not  appear  to  be  benefited  by 
treatment.  The  outlook  is  better  in  men  than  in  women.  The  complaint  is 
not  in  itself  fatal.  The  age  of  the  patient  has  little  influence  on  the  course  of 
the  illness,  nor  has  the  presence  of  intestinal  sand,  which  is  not  uncommon. 


138  INDEX     OF     PROGNOSIS 

Ulcerative. — The  outlook  is  exceedingly  serious  if  the  disease  is  in  any  way 
severe,  many  of  the  patients  dying  within  the  course  of  the  first  few  months 
after  presenting  themselves  for  treatment.  Grave  symptoms  are  high  fever, 
marked  distention  from  flatus,  severe  haemorrhage,  copious  diarrhoea,  exhaustion, 
and,  more  rarely,  peritonitis.  Death  may  occur  in  three  or  four  days  from  the 
first  onset  of  symptoms,  and  frequently  occurs  within  the  first  two  months. 
It  must,  however,  be  remembered  that  many  of  these  patients  give  a  history  of 
previous  attacks  of  diarrhoea,  and  if  the  onset  of  the  illness  is  measured  from 
the  first  of  these,  the  duration  is  often  many  years.  On  the  other  hand,  life 
may  be  prolonged  with  continuous  subacute  symptoms  for  upwards  of  two  years, 
and  in  a  small  proportion  of  cases  permanent  cure  apparently  results  from 
treatment,  even  when  the  disease  has  been  very  acute  and  severe.  The  vast 
majority  of  cases  run  their  course  either  to  death  or  recovery  without  complica- 
tions. Though  perforative  peritonitis  may  occur,  it  is  much  less  common 
than  might  be  supposed  when  the  extensive  area  of  ulcerated  surface  is  taken 
into  account.  Hepatic  abscess  is  very  rare  indeed.  Pulmonary  embolism 
sometimes  kills.  In  cases  which  recover,  there  is  little  liability  to  obstruction 
of  the  bowels  from  cicatrization. 

The  mortality  is  higher  than  in  tropical  dysentery  ;  thus  death  occurred  in 
40  out  of  55  cases  treated  at  Guy's  ;  28  out  of  32  at  St.  Bartholomew's  ;  9  out 
of  19  at  St.  George's  ;   8  out  of  19  at  St.  Mary's  ;  40  out  of  80  at  St.  Thomas's. 

The  mode  of  death  in  the  St.  Thomas's  Hospital  series  was  as  follows  :  8 
children,  all  died  from  exhaustion  following  diarrhoea.  Of  32  adults,  9  died  from 
exhaustion  following  diarrhoea  ;  i  from  haemorrhage  ;  8  from  haemorrhage  and 
diarrhoea  ;  i  from  hepatic  abscess  ;  6  from  peritonitis  after  perforation  ;  2 
from  peritonitis  without  perforation  ;  5  from  peritonitis  following  closure  of 
.an  artificial  anus. 

At  the  present  time  there  is  not  sufficient  evidence  upon  which  to  base  a 
prognosis  from  the  predominant  organism  present  in  the  evacuations,  or  from 
agglutination  tests.     The  sex  of  the  patient  does  not  influence  the  outlook. 

It  is  questionable  whether  the  use  of  vaccines  materially  modifies  the  prognosis. 
Improvement  and  sometimes  cure  have  followed  their  use  at  times  ;  on  the 
other  hand,  they  have  frequently  no  effect  in  arresting  the  course  of  the  disease 
or  preventing  a  fatal  termination. 

Tropical  Baeillary  Dysentery  [See  also  Dysentery). — This  disease  varies  very 
greatly  indeed  in  its  virulence.  Mild  cases  are  rapidly  cured  and  the  prognosis  is 
extremely  good.  The  severity  of  the  earliest  symptoms  forms  an  important  guide. 
The  mortality  of  epidemics  of  average  severity,  such  as  those  which  occur  in 
Japan,  is  about  30  per  cent.  Convalescence  is  very  liable  to  be  slow,  and  a 
return  of  the  symptoms  not  uncommon.  A  great  deal  depends  on  the  time  at 
which  the  illness  first  comes  under  treatment,  for  if  taken  in  hand  early  the 
prognosis  is  good,  while  if  neglected  in  the  earUer  stages  it  is  very  liable  to 
become  chronic  with  a  poor  outlook,  A  very  guarded  prognosis  must  be  given 
if  the  temperature  remains  elevated.  The  presence  of  a  leucocytosis  is  un- 
common, but  even  if  it  occurs  in  any  given  case,  it  does  not  necessarily  involve 
a  bad  prognosis.  The  choleraic  form  of  acute  baeillary  dysentery  is  usually 
fatal,  but  the  prognosis  appears  to  be  decidedly  improved  since  the  introduction 
of  the  use  of  the  intravenous  hypertonic  solution  of  Leonard  Rogers  (i.e.,  sodium 
chloride  120  gr.,  potassium  chloride  6  gr.,  calcium  chloride  4  gr.,  to  a  pint  of 
water),  combined  with  rectal  injection  of  calcium  permanganate  (5  gr.  to  the 
pint). 

The  chronic  form  generally  gets  well  or  ends  fatally  in  the  course  of  a  few 
months,  but  may  last  for  several  years  with  relapses.     A  retracted  abdomen. 


COLITIS  139 

gross  anaemia,  emaciation,  exhaustion,  oedema  of  the  extremities,  offensive 
stools,  are  all  bad  signs.  In  rare  cases  the  patient  may  succumb  to  haemorrhage. 
Perforation,  peritonitis,  and  hepatic  abscess  are  very  unusual.  Leonard  Rogers 
says  that  in  125  post-mortem  examinations  on  dysenteric  cases  in  Calcutta, 
no  case  of  portal  pyaemia  or  serious  hepatic  complication  was  found  in  any  of 
the  bacillary  cases,  which  numbered  36  per  cent  of  the  whole.  He  also  points 
out  that  the  mortality  from  bacillary  dysentery  among  the  Mecca  pilgrims, 
which  in  1909  was  64-4  per  cent,  was  reduced  by  serum  treatment  in  1910  to 
IO-8  per  cent. 

The  inore  frequent  use  of  a  Shiga,  Flexner,  or  polyvalent  antidysenteric 
serum  promises  to  improve  the  outlook  still  further.  Unfortunately  the  same 
cannot  as  yet  be  claimed  for  vaccine  treatment. 

Leonard  Rogers  gives  the  following  figures  of  the  case  mortality  in  India 
from  1906  to  1910  :  British  army,  2-93  per  cent ;  Indian  arm}',  0-51  per  cent  ; 
Indian  gaols,  5-29  per  cent. 

Sprue. — The  prognosis  is  very  unsatisfactory  unless  the  patient  comes  under 
treatment  at  the  earliest  possible  moment.  If  the  disease  is  of  long  standing, 
no  recognized  remedy  has  any  very  great  influence  on  the  course  of  the  illness. 
Typical  or  severe  mouth  symptoms  indicate,  as  a  rule,  an  advanced  state  of 
the  disease. 

In  addition  to  the  diarrhoea,  the  following  are  all  bad  signs  :  anaemia, 
diminution  in  the  size  of  the  liver,  and  emaciation.  Many  of  the  more  acute 
cases  succumb  within  eight  to  twelve  months  of  the  beginning  of  the  trouble, 
but  if  they  survive  this  period  they  tend  to  lapse  into  a  very  chronic  condition, 
with  a  disease  which  lasts  eight  to  ten  years  or  even  longer.  The  prognosis 
appears  to  be  improved  by  residence  in  a  temperate  climate.  Temporary 
improvements  are  often  followed  by  relapses,  even  if  the  patient  has  made  an 
apparent  cure  in  a  temperate  climate. 

Amoebic  Dysentery. — Children  suffer  from  the  disease  less  severely  than 
adults,  and  natives  of  a  place  where  amoebic  dysentery  is  endemic  are  more 
easily  treated  satisfactorily  than  others. 

In  acute  dysentery,  periods  of  apparent  improvement,  which  are  most 
delusive,  sometimes  occur,  during  which  the  stools  become  less  frequent  and 
offensive,  and  tenesmus  much  less  marked.  These  periods  of  calm  may  be 
followed  by  severe  relapse  of  symptoms.  Marked  prostration  shoald  cause  a 
very  guarded  prognosis.  In  acute  fulminating  cases,  peritonitis  from  perforation, 
gangrene  of  the  gut,  post-colic  abscess,  or  exhaustion,  may  kill  the  patient 
even  within  a  week  or  ten  days  from  the  onset.  Severe  haemorrhage  may  occur, 
but  this  is  a  very  rare  cause  of  death.  The  patient  must  not  be  regarded  as 
out  of  danger  because  there  is  no  fever,  for  many  cases  prove  fatal  without 
elevation  of  temperature.  Palpable  thickening  of  the  bowel,  most  frequently 
felt  over  the  caecum  and  sigmoid  and  often  associated  with  great  tenderness, 
may  be  present  in  severe  cases.  If  more  widespread  thickening  of  the  bowel 
can  be  felt,  the  case  is  generally  one  of  the  acute  fulminating  class,  and  the 
prognosis  grave  in  the  extreme.  The  mortality-rates  vary  from  20  per  cent 
to  43  per  cent ;  but  much  depends  on  the  stage  at  which  the  disease  comes  under 
treatment,  and  the  particular  type  in  any  given  case.  Chronic  amoebic  dysentery 
may  last  for  a  year,  and  even  then  be  liable  to  repeated  relapses. 

The  figures  just  quoted  refer  to  the  prognosis  before  the  introduction  of 
emetine.  The  outlook  appears  to  have  been  wonderfully  improved  since  Leonard 
Rogers  introduced  the  method  of  the  hypodermic  administration  of  the  soluble 
salts  of  emetine.  Solutions  of  these  salts  may  also  be  injected  with  very  great 
success  into  amoebic  abscess-cavities  in  liver  or  spleen.     When  no  more  amoebae 


I40  INDEX     OF     PROGNOSIS 

can  be  discovered  in  the  stools,  or  not  found  at  all  owing  to  the  closed 
nature  of  the  lesion,  the  progress  of  the  Leucoctyosis  is  most  important,  both 
from  the  point  of  view  of  prognosis  and  of  continuance  of  the  treatment. 
Absence  of  leucocytosis  in  acute  amoebic  dysentery  is  of  bad  omen,  indicating 
extremely  feeble  resistance. 

In  the  case  of  a  cured  abscess,  the  leucocytosis  should  have  disappeared  in 
about  a  fortnight.  With  an  uncomplicated  intestinal  lesion,  it  disappears  much 
sooner.  A  case  with  over  30,000  leucocytes  per  c.mm.  should  be  regarded  with 
considerable  gravity. 

Liver  abscess  may  arise  without  dysenteric  symptoms  being  evident.  If, 
however,  these  are  prominent,  the  prognosis  is  much  worse,  because  there  is 
then  much  more  probability  of  the  liver  suppuration  being  multiple.  Many  of 
these  cases  are  practically  hopeless.  If  the  abscess  is  single,  and  even  of  great 
size,  it  rarely  destroys  sufficient  tissue  to  make  recovery  impossible.  Secondary 
septic  infection  is  very  liable  to  follow  an  open  operation,  and  this  very  frequently 
kills  the  patient  if  the  abscess  is  large. 

Emetine,  if  used  early  enough,  appears  to  prevent  to  a  very  great  extent 
the  hepatic  complications,  and  to  have  a  marked  curative  effect  if  they  are 
already  present.  /.  r   Charles. 

COLON,  CARCINOMA  OF. — Compared  with  the  average  rate  of  growth  of 
cancer  elsewhere,  carcinoma  of  the  large  intestine  is  not  a  particularly  rapid  or 
malignant  type  of  the  disease.  It  is  certainly  more  favourable  than  cancer  of 
the  rectum.  As  Paul  has  pointed  out,  and  contrary  to  the  generally-received 
opinion,  the  hypertrophic  form,  in  which  a  large  tumour  can  be  felt,  is  less 
rapidly  fatal  than  the  stenosing  form,  which  causes  chronic  or  acute  intestinal 
obstruction.  The  duration  of  life,  from  the  first  onset  of  symptoms  to  the  end, 
is  usually  from  six  months  to  two  years,  apart  from  treatment.  In  the  great 
majority  of  cases  the  eventual  fatality  is  due  to  an  attack  of  acute  obstruction  ; 
less  often,  to  cachexia  ;    and  rarely,  to  perforative  peritonitis. 

Marked  ansemia  and  loss  of  flesh,  or  symptoms  of  obstruction,  show  that  the 
end  is  not  far  off. 

Results  of  Surgical  Treatment. — The  mortality  of  operation  depends  very 
greatly  on  the  state  of  the  patient  when  the  surgeon  sees  the  case  ;  also,  to  some 
extent,  on  the  method  of  intervention.  If  signs  of  acute  obstruction  are  already 
present,  the  outlook  is  very  grave,  and  all  that  can  be  done  at  the  moment  is  a 
colostomy  ;  but  occasionally  the  patient  may  recover  sufficiently  to  allow  of  a 
subsequent  radical  operation.  Cases  with  cachexia  are  already  beyond  hope  of 
cure,  though  it  may  be  possible  to  give  some  rehef. 

It  will  be  perfectly  evident,  from  the  figures  supplied,  that  a  two-stage 
operation  is  decidedly  the  safer,  probably  giving  a  mortality  of  about  15  per  cent. 
This  refers  to  cases  in  which  there  is  no  acute  obstruction  present.  By  a  two- 
stage  operation  is  meant,  either  Paul's  method,  in  which  the  growth  is  resected 
and  a  drainage  tube  tied  into  each  end  of  the  bowel  at  the  first  operation, 
the  spur  being  reduced  and  the  fistula  closed  subsequently  ;  or  a  preliminary 
colostomy,  followed  by  resection  and  end-to-end  union. 

The  best  results  after  the  one-stage  operation  are  from  the  Mayo  clinic,  where 
8  died  out  of  61  operated  on,  or  13  per  cent  ;  but  in  Finkelstein's  series,  including 
the  patients  of  the  Mayos  and  several  other  surgeons,  the  mortality  in  209  cases 
is  29  per  cent. 

Apart  from  acute  obstruction  cases,  the  mortality  is  given  by  various  writers 
as  follows  : — 


COLON,     CARCINOMA     OF 


141 


Mortality  of  Operation  for  Carcinoma  of  Colon. 


Reporter 

Operation 

Cases 

Died 

per  cent. 

/'*Finkelstein- 

Two-stage 

142 

16 

J  Paul     -        -        -        - 

14 

0 

j  Anschiitz 

30 

20 

(^  *Moynihan  - 

32 

15 

f  *Finkelstein- 

One-stage 

209 

29 

J  Anschiitz 

20 

55 

1  *Moynihan  - 

68 

32-3 

l^Mavos  -        -        -        - 

61 

13 

,  *Hartmann  - 

Stages  not  specified 

143 

33-5 

1  St.  Thomas's  Hospital 

,,                  ,, 

58 

39-5 

<  Voelcker 

58 

46-5 

1  Caird    -        -        -        - 

,,                  ,, 

17 

35-2 

^  Lausanne     - 

" 

28 

10-0 

*  These  are  cases  collected  from  the  literature. 

Anschiitz's  reports  refer  to  cases  in  von  Mikulicz's  clinic  up  to  1907  ;  Voelcker's 
to  Czerny's  clinic  ;  Moynihan's  tables  were  published  in  1906  ;  Finkelstein's 
relate  to  the  years  1907  to  191 2.  Very  probably  several  of  the  series  taken  from 
the  literature  include  the  same  groups.  Paul's  cases  are  all  from  his  private 
practice.  The  Lausanne  series,  published  by  Voichoud,  relate  to  the  years  1880- 
1910.     In  19  cases  the  operation  was  in  one  stage. 

End-results  of  Operation. — These  are  not  unfavourable,  provided,  of  course, 
that  there  were  no  secondary  deposits  at  the  time  of  intervention,  and  that  the 
glands  were  removed.     Various  observers  report  as  follows  : — 

End-results  of  Operations  for  Carcinoma  of  Colon. 


Reporter 

Cases  followed 

Alive  and  well 

Period 

Mayo  - 

16 

9 

Over  three  years 

Anschiitz     - 

27 

14 

,,            ,, 

Moynihan    - 

49* 

J    9 

(22 

One  to  three  years 

Paul    - 

13t 

(1 

Over  tliree  years 
One  to  three  years 

Lausanne    - 

24 

J    6 
(   8 

Over  three  years 
Under  three  years 

*  Three  deaths  were  not  due  to  cancer,    t  Two  deaths  were  not  due  to  cancer, 

We  may  conclude,  therefore,  that  about  half  the  patients  are  cured.  Death 
from  recurrence  is  often  late.  In  4  of  Paul's  cases  it  took  place  from  two  and  a 
half  to  seven  years  after  the  operation. 

Palliative  Operations  include  colostomy  above  the  growth  to  relieve  obstruc- 
tion, and  a  short-circuiting  operation. 

Colostomy,  in  the  presence  of  an  acute  obstruction,  is,  of  course,  a  desperate 
performance,  and  frequently  the  patient  does  not  rally.  Of  64  cases  in  Paul's 
private  practice  in  which  this  operation  was  performed  for  malignant  disease, 
acute  obstruction  was  present  in  24,  and  9  of  these  died  soon  afterwards.  There 
were  no  fatalities  in  the  absence  of  acute  symptoms. 


142 


INDEX     OF     PROGNOSIS 


The  survival  afterwards  is  often  surprisingly  long,  should  the  patient  recover 
from  the  immediate  efiects  of  the  operation.  Of  Paul's  64  cases,  9  died  shortly- 
after  the  operation  ;  28  within  a  year  ;  17  one  to  three  or  more  3-ears  later  ; 
TO  were  alive  (all  for  more  than  a  year  and  up  to  ten  j-ears,  except  one.  Some 
of  these  presumably  had  a  resection  performed  later).  It  is  not  quite  clear  how 
many  of  these  long-survival  cases  had  a  subsequent  resection  ;  it  cannot  be 
many,  as  the  total  resections  for  cancer  were  only  14  in  number. 

It  is  a  mistake  to  suppose  that  these  patients  were  necessarih^  left  in  a  state 
of  misery.  Persons  with  a  colostomy  have  frequently  been  able  to  get  about 
their  duties  ;  a  lady  has  even  acted  as  hostess  through  a  London  season,  without 
serious  inconvenience,  wearing  a  colostomy  belt. 

We  have  no  adequate  figures  to  show  the  risks  or  successes  of  short-circuiting 
operations  in  cases  of  cancer  of  the  colon. 

To  sum  up,  then,  the  mortality  of  the  one-stage  operation  is  30  to  40  per  cent ; 
of  the  two-stage  operation  about  16  per  cent ;  and  about  half  the  patients  who 
survive  will  be  cured. 

References.  —  Paul,  Bnt.  Med.  Jour.  iqi2,  ii,  172;  Moynihan,  Abdominal 
Operations,  1906  ;  Makins,  "  Cancer  of  Colon,"  Burghard's  System  of  Operative 
Surgery  ;  Finkelstein,  Archiv.  f.  klin.  Chir.  1913,  July,  936  ;  Mayo,  Ann.  Surg. 
1909,  July,  200  ;  Voichoud,  Surg.  Gyn.  and  Obst.  1914,  ii,  248  (Summary). 

A.  Rendle  Short. 

CONCUSSION.— (5ee  Head  Injuries.) 

CONGENITAL  DISLOCATION  OF  HIP. — Apart  from  surgical  interference, 
the  outlook  in  this  deformity  is  not  favourable.  Natural  cure  appears  to  be 
unknown,  although  there  are  a  few  records  of  improvement  in  patients  with 
partial  dislocation  or  subluxation.  In  ordinary,  the  lameness,  shortening,  and 
difi&culty  in  walking  increase  rapidly  during  the  years  of  growth,  and  even  those 
children  in  whom  the  deformity  is  at  first  scarcely  noticeable  are  eventually 
seriously  crippled.  In  bilateral  cases  a  good  deal  of  spasm  often  develops,  and 
the  patient  may  become  a  chronic  invaUd. 

We  shall  have  to  consider  the  results  of  two  methods  of  treatment :  (i)  The 
open  operation  ;    and  (2)  The  "  bloodless  "  reduction  by  Lorenz's  method. 

1.  The  Open  Operation. — This  is  seldom  performed  now,  though  favoured 
by  Burghard.  There  has  been  a  considerable  mortahty,  and  it  is  apt  to  cripple 
the  muscles  a  good  deal.  Tubby  has  performed  it  10  times  ;  4  gave  a  good 
result,  and  6  relapsed. 

2.  The  Lorenz  Operation. — This  operation  is  only  suitable  within  narrow 
age-Hmits,  from  four  years  old  up  to  seven  in  bilateral,  or  ten  in  unilateral,  cases. 
The  risks  are  small.  There  is  almost  no  mortality,  4  deaths  in  1235  cases, 
according  to  Deutschlander — that  is,  about  0-3  per  cent.  Occasionally  the  femur 
may  be  fractured  ;  R.  Jones  mentions  that  he  has  seen  this  happen  4  times  in 
38  cases,  and  in  the  records  of  five  Continental  surgeons  it  appears  35  times  in 
856  cases  (4  per  cent).  A  transient  paral3rsis  sometimes  follows  the  mani- 
pulation— 23  times  in  755  French  and  German  cases — but  it  soon  clears  up. 

The  results  obtained  are  almost  always  an  improvement  on  the  previous 
condition,  and  often  terminate  in  a  more  or  less  perfect  cure,  but  usually 
there  is  some  slight  deviation  from  the  normal,  such  as  a  tendency  to  abduction. 
Putting  the  femur  in  place  undoubtedly  makes  it  grow  ;  Joachimstal  used  to 
reduce  one  leg  at  a  time  in  bilateral  cases,  and  found  that  the  bone  first  replaced 
became  longer  than  its  fellow. 

It  is  difficult  to  tabulate  the  success  of  the  operation,  because  writers  classify 
their  results  so  differently.     Lorenz,  dealing  with  572  cases,  claims  a  cure  in  63 


DIABETES    INSIPIDUS  143 

per  cent  ;  his  unilateral  cases  gave  slightly  better  results.  Hoffa  gives  only 
30  per  cent  of  250  unilateral  cases  as  showing  real  anatomical  restoration,  and 
only  7  per  cent  in  65  bilateral  cases.  Out  of  49  treated  by  Narath,  18  gave  an 
ideal  result,  12  very  good,  16  good,  and  3  medium  or  bad.  Stern  quotes  2593 
cases  from  the  literature,  with  the  following  results  :  4  per  cent  ideal  anatom- 
ically and  functionally  ;  7  per  cent  ideal  functionally  ;  40  per  cent  good  ;  12  per 
cent  poor. 

All  the  figures  given  are  previous  to  1905  ;  there  has  been  some  improvement 
in  technique  since  that  date. 

We  may  conclude  that  in  careful  hands,  accustomed  to  the  method,  about 
half  give  a  thoroughly  good,  almost  ideal,  result,  and  that  about  one  in  ten  is 
a  failure. 

References. — Tubby,  Deformities,  including  Diseases  of  Bones  and  Joints,  vol.  i ; 
Stern,  New  York  Med.  Rec.  1906.  ,j    ^^^^^^^  gJ^^^^_ 

CONGENITAL     MALFORMATIONS     OF     THE      HEART.  —  [See     Heart, 
CoNGENiTAi.  Malformations  of.) 

CONGENITAL  STENOSIS   OF  THE  PYLORUS.— (5ee  Pylorus,  Congenital 
Stenosis  of.) 

CONTUSION  OF  ABDOMEN.— (5ee  Abdominal  Injuries.) 

CONVULSIONS,  INFANTILE.— (See  Infantile  Convulsions.) 

COXA  VARA. — Apart  from  treatment,  the  condition  usually  gets  steadily 
worse,  the  shortening  becoming  more  noticeable  as  growth  proceeds.  Rarely, 
the  rickety  form  may  improve  ;  Hoffa  had  a  case  in  which  the  angle  of  the  femur 
increased  from  105°  to  120°  on  one  side,  and  110°  to  125°  on  the  other,  in  three 
years. 

Rest  and  extension  check  the  process,  but  do  not  rectify  the  deformity  already 
present.  The  best  results  are  obtained  by  subtrochanteric  osteotomy,  or  better 
still  by  Whitman's  method,  that  is,  removal  of  a  wedge  with  its  apex  at  the 
lesser  trochanter.  Section  of  the  neck  of  the  femur  is  risky  ;  one  death  from 
sepsis  is  recorded,  and  two  cases  of  necrosis  of  the  severed  head. 

Reference. — ^Tubby,  Deformities,  including  Diseases  of  Bones  and  Joints,  vol.  1. 

A.   Rendle  Short. 

CYSTITIS. — [See  Pyelocystitis  ;    Bladder,   Tuberculosis  of.) 
CYSTS,  PANCREATIC— (See  Pancreatic  Cysts.) 
DECIDUOMA  MALIGNUM.— (See  Chorion-epithelioma.) 
DELHI  BOIL.— (See  Tropical  Fevers.) 
DEMENTIA. — (See  Mental  Diseases.) 
DENGUE.— (See  Tropical  Fevers.) 

DIABETES  INSIPIDUS. — This  name  is  applied  to  cases  in  which  very  large 
quantities  of  urine  are  passed  without  any  signs  pointing  to  disease  of 
the  kidneys.  Little  is  known  of  the  nature  of  the  malady,  though  attempts  have 
been  made  to  differentiate  certain  types — hydruria,  polyuria,  phosphaluria, 
axoturia. 


144  INDEX     OF     PROGNOSIS 

Hydruria  or  Polyuria. — This  common  form  of  the  disease  occurs  chiefly  in 
children,  and  more  often  in  those  of  the  poor.  The  condition  may  arise  suddenly 
or  gradually.  No  certain  prognosis  can  be  given  until  the  course  of  the  case 
has  been  carefully  observed.  Some  cases  continue  for  many  years  without 
giving  rise  to  inconvenience,  beyond  the  frequent  micturition  ;  others  terminate 
fatally  within  a  few  months.  A  sudden  onset  is  more  favourable  than  an 
insidious  invasion,  as  the  condition  may  subside  as  suddenly  as  it  appeared  ; 
cases  of  this  kind  associated  with  injuries  to  the  head  have  the  most  hopeful 
outlook  ;   those  which  follow  some  shock  are  also  likely  to  recover. 

Chronic  cases,  with  insidious  onset,  and  accompanied  by  wasting,  loss  of 
appetite,  dryness  of  the  skin,  and  increasing  weakness,  are  likely  to  end  fatally 
within  five  or  six  months  ;  those,  however,  which  cause  no  symptoms  may  last 
long,  sometimes  exhibiting  acute  exacerbations  and  comparative  remissions. 
Children  of  tuberculous  parents  usually  do  badly  ;  those  presenting  signs  of  a 
syphilitic  taint  may  recover  on  appropriate  treatment.  In  a  certain  proportion 
of  cases,  diabetes  mellitus  supervenes  and  proves  fatal,  while  tuberculosis  of  the 
lungs  may  be  the  cause  of  death,  as  in  the  latter  malady. 

Several  different  methods  of  treatment  have  been  proposed,  in  comparatively 
recent  years,  which  cause  the  general  outlook  in  these  cases  to  be  better  than 
formerly.  One  of  these  is  the  withdrawal  of  salt  from  the  dietary,  on  the  ground 
that  the  malady  consists  in  an  inability  of  the  kidneys  to  excrete  this  substance 
except  in  extremely  dilute  solution,  an  enormous  flow  of  water  being  thus 
necessitated.  A  connection  has  also  been  traced  between  diabetes  insipidus 
and  disturbance  of  the  pituitary  body,  and  the  use  of  preparations  of  pituitary 
substance  has  seemed  to  modify  the  disease.  It  is  stated  that  cases  marked  by 
infantilism,  with  headache  and  contracted  visual  fields,  may  be  treated  with  an 
extract  of  the  anterior  lobe  of  the  pituitary  body  ;  cases  with  obesity,  drowsiness, 
and,  in  females,  amenorrhoea,  with  extract  of  the  posterior  lobe.  The  skull  may 
be  skiagraphed  to  endeavour  to  find  evidence  of  alteration  of  the  sella  turcica. 
This  method  of  treatment  is,  however,  in  its  infancy,  and  nothing  certain  is  known 
of  its  results. 

Azoturia. — Examination  of  the  urine  may  show  the  continued  passage  of 
increased  quantities  of  urea,  the  condition  being  usually  accompanied  by  languor 
and  aching  in  the  loins,  and  sometimes  by  increased  appetite  as  well  as  thirst. 
These  cases  generally  do  well  if  treated  early  by  rest,  change  of  scene,  and  hydro- 
therapy (Carlsbad,  Homburg) .  If  neglected,  the  condition  may  pass  into  one  of 
saccharine  diabetes,  or  emaciation  may  supervene,  and  gradual  or  sudden  death. 

Phosphaturia. — In  some  instances,  which  clinically  resemble  the  above,  the 
amount  of  phosphates  contained  in  the  urine  is  increased  even  more  markedly 
than  the  urea.  The  patients  are  irritable,  and  suffer  from  digestive  disturbances. 
The  treatment  is  similar  to  that  just  described,  and,  if  taken  early,  these  patients 
do  well. 

References. — Bradford,  in  Allbutt  and  Rolleston's  System  of  Medicine,  vol.  iii, 
p.  212  ;    Jewitt,  Med.  Record,  1914,  242.  iy_  Cecil  Bosanquet. 

DIABETES  MELLITUS. — The  true  nature  of  diabetes,  and  its  relationship 
to  other  forms  of  glycosuria,  are  still  unknown,  so  that  for  practical  purposes 
they  must  all  be  considered  together.  No  useful  distinction  can  be  drawn 
between  persistent  glycosuria  and  mild  diabetes  mellitus,  and  from  time  to  time 
apparently  mild  cases  pass  into  the  grave  affection.  With  a  view  to  prognosis, 
it  may  be  most  convenient  to  sketch  the  course  of  a  few  typical  cases  of  varjdng 
severity,  and  then  to  endeavour  to  indicate  points  which  may  be  used  to  assign 
individual  patients  to  one  or  other  group. 


DIABETES    MELLITUS  145 

Typical  Varieties. — 

I.  Alimentary  Glycosuria. — A  young  or  middle-aged  man,  feeling  out  of  sorts 
after  a  copious  meal  accompanied  by  many  '  sweets,'  is  examined  by  a  doctor, 
and  the  urine  is  found  to  contain  sugar.  On  the  following  day,  this  has 
disappeared.  A  similar  experience  subsequently,  or  a  test-administration  of 
glucose,  proves  him  to  be  the  subject  of  alimentary  glycosuria.  With  a  little 
care  in  avoiding  dietary  indiscretions,  he  remains  free  from  any  disturbance  of 
health. 

In  addition  to  this  form  of  alimentary  glycosuria,  there  are  a  number  of  cases 
of  transient  glycosuria  which  hardly  amount  to  disease,  and  constitute  no  danger 
to  life  or  health  in  themselves.  Thus,  closely  allied  to  the  alimentary  form,  but 
by  some  classed  as  a  renal  glycosuria,  is  the  condition  often  seen  in  pregnant 
women,  whose  urine  may  from  time  to  time  contain  small  quantities  of  sugar 
(apart  from  their  well-known  lactosuria)  which  disappears  after  delivery  [see 
below).     Eaton  and  Woods  state  that  similar  glycosuria  is  common  in  infants. 

A  form  of  glycosuria  apparently  associated  with  disorder  of  the  liver,  but 
possibly  rather  to  be  assigned  to  coincident  pancreatic  disturbance,  occurs  in 
alcoholic  subjects.  Quite  large  amounts  of  sugar  may  be  present  in  the  urine 
for  a  considerable  period  of  time  ;  yet,  on  cutting  off  the  supplies  of  intoxicants, 
complete  recovery  may  take  place.  A  somewhat  similar  recovery  may  occur 
in  syphilitic  subjects  as  a  result  of  suitable  treatment  (mercury,  iodide,  salvarsan). 
It  is  wise,  therefore,  to  withhold  a  definite  opinion  in  regard  to  such  persons  until 
a  suitable  regimen  has  been  adopted,  and  continued  for  some  months. 

2.  Chronic  Glycosuria  [Chronic  Diabetes). — A  middle-aged  man  of  sedentary 
habits,  engrossed  in  business  anxieties,  stout  of  build,  and  with  gouty  tendencies, 
is  found  to  suffer  from  glycosuria.  On  strict  diet  the  sugar  disappears,  but  the 
patient  cannot  tolerate  strict  dieting.  On  a  diet  containing  a  moderate  amount 
of  starchy  materials  he  continues  to  pass  2  to  5  per  cent  of  sugar,  but  suffers  no 
apparent  inconvenience,  living  to  a  fair  age,  and  ultimately  dying  of  cerebral 
hsemorrhage  or  arteriosclerotic  heart  failure. 

3.  Diabetes  of  Moderate  Severity. — A  middle-aged  man  notices  that  he  is 
losing  flesh  and  strength,  while  his  urine  is  increased  in  quantity  and  he  is 
unusually  thirsty.  On  being  questioned,  he  admits  that  he  has  not  been  well 
for  the  past  year,  and  that  the  symptoms  have  gradually  developed.  The  urine 
is  found  to  contain  a  moderate  amount  of  sugar.  On  a  strict  diet  this  gradually 
falls  in  amount  and  finally  disappears,  and  it  is  ascertained  that  a  small  amount 
of  carbohydrate  can  be  allowed  without  the  return  of  glycosuria.  On  a  restricted 
diet  he  remains  well  for  some  months,  but  the  glycosuria  returns  and  a  still  more 
limited  diet  is  necessitated.  Later  still,  no  reduction  of  carbohydrates  is  found 
to  be  efficient,  and  the  urine  always  contains  a  considerable  quantity  of  sugar. 
The  patient  perhaps  suffers  from  itching  of  the  skin,  or  from  boils  and  pustules. 
Finally  acetone  and  diacetic  acid  appear  in  the  urine,  perhaps  accompanied  by 
albumin  and  casts,  and  the  patient  dies  comatose  after  an  illness  of  seven  or  eight 
years. 

4.  Acute  Diabetes. — A  boy,  aged  ten  to  fourteen  years,  suffers  from  thirst, 
hunger,  polyuria,  and  increasing  weakness,  all  of  which  symptoms  have  arisen 
within  the  period  of  a  week  or  ten  days.  When  seen  by  the  doctor,  he  is  weak 
and  drowsy,  with  a  flushed  face,  and  a  red  tongue  covered  on  the  dorsum  with 
thick  fur.  His  breath  smells  of  acetone,  and  this  substance,  togetlier  with 
diacetic  acid  and  glucose,  are  present  in  tlie  urine.  On  a  diet  containing  a  limited 
aniount  of  carbohydrate,  aided  by  doses  of  liquor  morphinas  and  administration 
of  sodium  bicarbonate,  in  draclim  doses,  by  the  rectum,  he  improves  :  the  drowsi- 
ness passes  off,   the  acetone    bodies  disappear  from  the  urine,   and  the  sugar 

10 


146  INDEX     OF     PROGNOSIS 

diminishes  in  amount,  but  does  not  disappear.  On  careful  diet  the  boy  remains 
comparatively  well  for  six  months,  when  the  former  symptoms  return,  to  yield 
once  more  to  treatment.  A  second  period  of  comparative  health  is  followed  by 
a  second  relapse :  treatment  is  ineffectual,  air-hunger  is  noticed,  and  increasing 
drowsiness,  deepening  into  coma  and  death.  The  whole  illness  has  lasted  a  little 
over  eighteen  months  from  the  first  onset  of  symptoms. 

Coming  to  the  cases  which  are  usually  classified  as  diabetes  mellitus,  no  general 
rules  as  to  probable  duration  can  be  laid  down.  Feilchenfeld  found  that,  of  154 
cases,  30  per  cent  lived  over  ten  years  after  recognition  of  the  malady.  The 
shortest  case  which  I  have  found  recorded  is  that  of  a  girl,  aged  seventeen,  who 
developed  acute  diabetes  after  typhoid  fever,  and  died  in  eleven  days  (Laache). 
Chronic  cases  may  last  over  thirty  years.  It  will  be  convenient  to  consider 
seriatim  the  various  factors  which  influence  the  prognosis. 

Factors  Influencing  the  Prognosis. — 

Age. — As  a  general  statement,  it  may  be  said  that  the  younger  the  patient  the 
worse  is  the  outlook.  In  infants  and  young  children,  the  course  of  the  disease 
is  very  rapid — seldom  more  than  twelve  to  eighteen  months.  It  is  doubtful  if 
recovery  ever  takes  place  in  established  cases,  but  Mason  Knox,  who  collected 
16  cases  occurring  within  the  first  year  of  life,  states  that  he  found  records  of  2 
recoveries.  In  rather  older  children,  a  similar  brief  course  is  common.  In 
young  adults,  the  outlook  is  scarcely  better,  a  fatal  termination  almost  invari- 
ably ensuing  within  two  or  three  years.  In  those  over  twenty-five,  the  course  is 
likely  to  be  less  rapid,  and  the  patient  may  live  seven  or  eight  years  if  carefully 
looked  after.  In  subjects  over  forty,  the  course  of  the  affection  is  usually  much 
more  prolonged,  a  duration  of  ten  to  fifteen  years  being  common.  Acute  cases 
are,  however,  to  be  encountered  at  almost  all  ages. 

Sex. — The  outlook  does  not  appear  to  be  strikingly  different  in  the  two  sexes ; 
but  cases  occurring  in  women  about  the  climacteric  are  said  to  be  specially 
amenable  to  treatment.  It  seems  likely  that  they  are  often  instances  of  glycos- 
iiria  due  to  disturbance  of  internal  secretions  coincident  with  ovarian  atrophy. 

Obesity. — Diabetes  or  glycosuria  occurring  in  fat  persons  usually  runs  a  slow 
course,  often  without  much  apparent  disturbance  of  health,  though  various 
complications  may  be  present  from  time  to  time.  Hence  the  French  have 
classified  the  disease  into  two  forms,  diabete  gras  and  diabete  maigre,  the  latter 
being  the  dangerous  form.  The  stout  diabetics  often  exhibit  gouty  symptoms, 
and  perhaps  more  often  die  from  arteriosclerosis  or  uraemia  than  from  coma — 
the  typical  diabetic  ending.     They  are  also  liable  to  cerebral  haemorrhage. 

Social  Position. — There  is  no  doubt  that  persons  who  are  well  off,  and  thus  able 
to  carry  out  a  strict  regime  of  diet  and  mode  of  life,  are  more  favourably  placed 
than  the  poor,  who  cannot  afford  luxuries  in  the  form  of  starch-free  foods,  rest, 
climatotherapy,  and  so  forth.  Acute  rapidly  fatal  cases  are  rare  among  the 
upper  classes.  Cases  in  middle-aged  persons  of  business  habits,  associated  with 
some  degree  of  worry  and  anxiety,  often  do  well  when  these  causes  are  eliminated 
by  rest  or  retirement. 

Family  History. — In  a  considerable  number  of  cases,  other  members  of  the 
patients'  families  have  suffered  from  diabetes.  Some  idea  as  to  the  probable 
severity  or  chronicity  of  the  case  may  be  gleaned  from  what  has  happened  to  the 
others  ;  but  no  great  reliance  can  be  placed  on  such  evidence,  as  some  cases  in 
a  family  may  be  grave  and  others  comparatively  mild. 

Onset. — An  acute  onset  with  severe  symptoms  is  of  bad  omen,  whereas  a 
.gradual  increase,  with  periods  of  improvement  or  quiescence,  points  to  a  likeli- 
hood of  a  long  course ;  but  such  a  rule  is  far  from  absolute.  Some  instances  which 
follow  an  acute  infective  disease  yield  readily  to  treatment,  while  mild  cases  may 


DIABETES    MELLITUS  147 

develop  into  severe  ones  :  this,  however,  according  to  von  Noorden,  is  rare,  at 
all  events  if  patients  submit  to  strict  regimen.  Cases  associated  with  head 
injuries  may  completely  recover  ;  they  should  probably  be  called  glycosuria 
rather  than  diabetes. 

Symptoms. — Great  thirst  and  increased  appetite  point  to  severe  diabetes,  but 
the  absence  of  these  symptoms  does  not  necessarily  imply  that  the  affection  is 
of  mild  type  ;  indeed,  loss  of  appetite  may  be  a  bad  sign  if  it  has  previously  been 
large  or  moderate.  Wasting  is  rapid  in  grave  cases,  and  it  is  useful  to  weigh  the 
patients  regularly  every  week,  as  much  information  as  to  progress  or  retro- 
gression may  be  thus  obtained  ;  a  patient  who  is  gaining  weight  is  usually  doing 
well.  Constipation  is  usual,  and  may  be  difficult  to  treat,  but  does  not  necessarily 
affect  the  outlook.  On  the  other  hand,  diarrhoea  is  a  bad  sign,  and,  if  intractable, 
is  often  found  to  be  a  forerunner  of  coma.  Severe  epigastric  pain  is  another 
warning  signal  which  should  not  be  neglected.  Drowsiness  may  precede  actual 
loss  of  consciousness  by  some  days,  and  should  always  excite  alarm.  The  smell 
of  acetone  in  the  breath  may  be  the  first  warning  of  the  grave  intoxication  which 
is  accompanied  by  the  presence  of  acetone  bodies  in  the  urine,  but  regular 
examination  of  the  urine  will  always  show  the  presence  of  traces  of  these 
substances  in  this  secretion  before  it  is  noticeable  elsewhere.  It  may  be  worth 
noting  that  acetonuria  may  be  found  apart  from  diabetes  mellitus  (cyclical 
vomiting  of  children,  etc.),  but  it  is  always  of  serious  import. 

The  Urine. — ^The  continued  passage  of  very  large  quantities  of  urine  is  usually 
a  sign  of  grave  disease,  and  diminution  in  the  amount  passed  is  often  an  early 
sign  of  improvement.  Very  large  amounts  of  sugar  are  also  bad,  but  it  cannot 
be  said  that  the  severity  of  the  case  is  directly  proportional  to  the  saccharin 
output ;  this  varies  with  the  diet  taken  and  with  other  factors.  Thus,  the  sugar 
may  be  much  diminished,  or  actually  disappear,  just  before  the  onset  of  coma; 
so  that  such  an  occurrence  in  the  presence  of  grave  symptoms  is  an  alarming 
sign.  In  chronic  senile  cases,  the  percentage  of  sugar  and  its  total  amount  are 
usually  small.  In  the  presence  of  intercurrent  infective  disease  {see  below),  the 
sugar  may  diminish  or  disappear  from  the  urine.  The  most  important  considera- 
tion in  connection  with  the  urinary  sugar  is  the  effect  of  restricted  diet  in  reducing 
the  quantity  excreted.  The  usual  procedure,  in  respect  to  cases  seen  for  the  first 
time,  is  to  estimate  the  quantity  of  sugar  passed  for  two  or  three  days  on  a  normal 
diet,  and  then  gradually  to  reduce  the  amount  of  carbohydrate  food,  substituting 
such  materials  as  casoid  bread,  gluten,  saccharin,  etc.,  for  the  ordinary  bread, 
potatoes,  sugar,  etc.,  taken.  When  all  starchy  food  has  thus  been  withdrawn,  the 
quantity  of  sugar  in  the  urine  is  again  estimated  on  three  successive  days.  If  no 
sugar  is  found,  then  small  amounts  of  bread  or  potato  are  added  to  the  diet  until 
sugar  once  more  appears.  In  this  way  the  carbohydrate  tolerance  of  the 
individual  is  estimated.  If  some  120  grams  of  carbohydrate  can  be  taken  in 
twenty-four  hours  without  the  appearance  of  •  sugar  in  the  urine,  the  case  is  a 
mild  one,  and  the  patient  is  likely  to  live  for  many  years.  If,  on  the  other  hand, 
no  carbohydrate  can  be  taken  without  glycosuria,  the  disease  is  likely  to  be 
serious,  and  if  no  restriction  of  diet  causes  disappearance  of  the  sugar,  the  state 
of  affairs  is  manifestly  grave.  (It  need  hardly  be  noted  that,  in  all  cases  here 
dealt  with,  the  sugar  in  question  is  glucose.  Pentosuria  is  apparently  a  family 
or  hereditary  abnormality  of  metabolism,  and  is  of  no  importance  from  a  health 
point  of  view).  Repetition  of  similar  tests  of  tolerance  during  the  progress  of 
the  case  will  indicate  improvement  or  deterioration,  according  as  the  quantity 
ol:  carbohydrate  duly  assimilated  is  greater  or  less  than  at  first.  In  most  cases, 
the  degree  of  tolerance  tends  to  fall  as  time  goes  on. 

The  urine  should  be  tested  from  time  to  time  for  the  presence  of  acetone  and 


INDEX     OF    PROGNOSIS 


diacetic  acid.  The  ferric  chloride  test  for  the  latter  is  simple,  and  usually 
sufficient  for  practical  purposes,  as  the  two  bodies  are  generally  present  together. 
If  they  are  found,  the  aspect  of  the  case  immediately  assumes  a  graver  character, 
as  it  evidently  belongs  to  the  class  of  severe  diabetes  and  is  likely  to  terminate 
sooner  or  later  in  coma.  It  must  not,  however,  be  assumed  that  this  is  imminent, 
for  acetone  bodies  may  appear  and  disappear  for  considerable  periods  of  time 
without  fatal  issue.  A  definite  increase  in  the  amounts  of  acetone  and  diacetic 
acid  excreted  is  a  cause  for  anxiety,  especially  if  the  patient  tends  to  be  drowsy, 
or  if  the  quantity  of  sugar  diminishes  concurrently. 

The  appearance  of  any  considerable  amount  of  albumin  in  the  urine  is  of  bad 
omen,  though  small  quantities  may  be  found  from  time  to  time  in  chronic  gouty 
cases  without  any  serious  effects  resulting.  If  large  numbers  of  casts  are  also 
found,  the  condition  is  serious,  as  this  phenomenon  often  shortly  precedes  the 
fatal  issue.  Estimation  of  the  ammonia-content  of  the  urine  is  also  of  value  in 
prognosis,  any  large  increase  in  the  normal  quantity  being  associated  with 
acetonuria,  and  being  an  indication  of  approaching  coma. 

The  skin  in  diabetes  is  usually  dry  :  the  occurrence  of  a  tendency  to  sweat 
has  been  said  to  be  a  good  sign,  but  it  would  be  unwise  to  lay  any  stress  on  such 
a  point.  Pruritus  seems  to  be  more  troublesome  in  chronic  cases,  especially  in 
gouty  subjects.  Boils  may  be  troublesome,  but  are  not  often  of  serious  import. 
On  the  other  hand,  a  large  carbuncle  is  sometimes  a  grave  complication,  and  may 
give  rise  to  fatal  septic  intoxication  and  coma. 

Pigmentation  of  the  skin  in  association  with  glycosuria  is  sometimes  classed 
as  a  separate  disease,  hcsmochromatosis,  or  bronzed  diabetes.  The  features  are 
rather  those  of  cirrhosis  of  the  liver,  a  condition  usually  found  in  these  subjects 
after  death,  which  is  usually  due  to  intercurrent  disease  rather  than  to  coma. 
The  glycosuria  may  sometimes  disappear  while  the  other  symptoms  continue. 
The  duration  of  the  condition,  after  the  phenomena  have  become  well  marked, 
may  be  from  two  to  three  years,  but  some  patinets  may  succumb  within  a  few 
months. 

Nervous  System. — Loss  of  knee-jerks  is  commonly  noticed  in  diabetes,  and  seems 
to  be  of  no  special  importance  as  an  indication  of  the  severity  of  the  disease. 
Neuralgia  is  a  frequent  trouble,  especially  in  elderly  subjects,  but  does  not 
influence  the  general  prognosis.  It  usually  yields  to  rest  in  bed  and  regulation 
of  the  diet.  Most  of  the  sensory  disturbances  in  diabetes  are  associated  rather 
with  vascular  degeneration  than  with  true  peripheral  neuritis,  which  is  a  rare 
complication. 

Coma. — Until  recent  years,  the  prognosis  of  diabetic  coma  was  absolutely 
hopeless,  patients  invariably  dying  within  a  comparatively  small  number  of 
hours  after  the  condition  originated.  Even  now,  the  outlook  is  so  far  desperate 
that  a  fatal  termination  to  the  disease  is  almost  certain  to  ensue  before  many 
months  after  such  an  occurrence ;  but  in  many  instances  the  immediate  fatality 
may  be  averted  by  treatment,  at  all  events  in  the  commencing  stages  of  the 
condition.  Recovery  is  certainly  possible  from  a  state  of  deep  drowsiness  and. 
practical  unconsciousness  with  the  typical  symptoms  of  air-hunger,  under  the 
administration  of  large  doses  of  bicarbonate  or  carbonate  of  soda,  either  in  the 
form  of  enemata  or  by  intravenous  infusion.  The  administration  of  glucose 
itself  by  the  rectum  has  also  been  employed  in  this  condition,  which  is  supposed 
to  result  from  carbohydrate  starvation. 

Gangrene. — Dry  gangrene  in  diabetes  is  due  to  arterial  disease,  with  consequent 
deficiency  of  the  blood  supply  to  the  affected  part.  It  is  best  treated  expectantly, 
the  limb  being  kept  dry  and,  as  far  as  possible,  aseptic.  The  outlook  is  fairly 
good  under  these  conditions.  If  the  gangrene  is  moist,  pointing  to  bacterial 
infection,  amputation  is  necessary,  and  the  outlook  is  bad. 


DIABETES     MELLITUS  149 

Cataract. — The  appearance  of  cataract  in  an  infant  or  young  child  is  a  sign 
of  grave  disease  and  of  a  rapidly  fatal  issue.  In  any  acute  case,  operation  is 
unadvisable.  In  chronic  cases,  in  which  the  glycosuria  is  controlled  by  dieting, 
operation  is  often  quite  successful  ;  but  there  is  always  a  danger  of  local  haemor- 
rhage supervening. 

Intercurrent  Disease. — Acute  infective  disease  occurring  in  the  course  of 
diabetes  is  always  a  source  of  anxiety,  as  it  may  induce  fatal  coma.  This  is  not, 
however,  at  all  a  necessary  sequence,  as  diabetics  may  pass  through  severe 
illnesses  and  make  satisfactory  recoveries ;  but  the  prognosis  must  always  be 
guarded  until  complete  convalescence.  The  effect  produced  on  the  glycosuria 
is  variable.  In  some  instances,  the  sugar  disappears  from  the  urine  during  fever ; 
or  diminishes  markedly  ;  in  other  cases,  it  is  unaffected,  or  may  even  increase. 
A  fatal  diabetes  may  date  from  an  attack  of  acute  disease,  such  as  enteric  fever, 
though  it  is  difficult  to  make  sure  that  slight  symptoms  may  not  have  existed 
previously,  and  been  overlooked  until  the  urine  was  tested  regularly  in  the  course 
of  the  infective  disease.  Pneumonia  in  diabetics  is  almost  invariably  fatal, 
gangrene  of  the  lung  being  a  frequent  termination.  Erysipelas  and  other  troubles 
due  to  pyogenic  organisms  are  also  dangerous,  owing  to  the  diminished  resistance 
shown  by  the  tissues  in  these  patients.  Tuberculosis  of  the  lungs  is  a  common 
cause  of  death,  constituting  the  most  frequent  termination  after  coma  diabeticum. 
It  is  doubtful  if  recovery  from  this  infection  ever  occurs  in  true  diabetics,  but  its 
course  may  be  prolonged  for  two,  or  even  three,  years.  The  sugar  often  tends 
to  disappear  from  the  urine  as  the  pulmonary  disease  progresses.  In  grave  cases, 
a  fatal  issue  may  occur  in  two  or  three  months  after  signs  are  noticed  in  the  chest. 
The  prognosis  in  individual  cases  will  depend  on  the  rapidity  of  emaciation  and 
on  the  progress  of  signs  of  destruction  of  the  substance  of  the  lungs.  There  may 
be  fever  of  the  usual  hectic  type,  but  in  this,  as  in  other  infective  disorders, 
cases  are  met  with  in  which  grave  infections  run  their  course  with  little  or  no 
elevation  of  temperature. 

Pregnancy . — The  relationship  of  pregnancy  to  diabetes  is  not  well  understood. 
According  to  Franck,  transitory  glycosuria  occurs  in  40  per  cent  of  all  gravid 
women,  and  more  persistent  glycosuria  in  10  to  12  per  cent.  Whitridge  Williams 
believes  that  if  the  symptom  occurs  late  in  pregnancy,  and  the  sugar  is  not  more 
than  2  per  cent,  while  there  are  no  symptoms  of  ill-health,  the  condition  is 
transitory  and  unimportant ;  if  it  occurs  early,  or  in  larger  amount,  no  prognosis 
should  be  given  till  delivery  has  taken  place  and  the  progress  of  affairs  been 
observed.  Diabetic  patients  may  make  good  recoveries  from  the  troubles  of 
labour,  or  may  die  in  coma.  If  the  amount  of  sugar  in  the  urine  is  large,  and 
uncontrolled  by  diet,  artificial  labour  should  be  induced.  I  have  known  a  case 
in  which  glycosuria  occurred  in  one  pregnancy,  with  increased  thirst  and 
polyuria,  to  pass  off  after  delivery,  and  return  again  with  the  next  pregnancy, 
the  case  then  becoming  one  of  confirmed  diabetes.  A  cautious  prognosis  is 
certainly  necessary  in  all  these  cases. 

Surgical  Operations. — Diabetics  may  make  good  recoveries  from  severe  surgical 
procedures  ;  on  the  other  hand,  coma  may  ensue  and  prove  fatal.  This  risk 
makes  it  wise  to  avoid  all  unnecessary  operations  of  a  trivial  or  cosmetic  nature ; 
but  dangerous  conditions,  such  as  appendicitis  or  cancer,  which  in  themselves 
threaten  life,  should  be  treated  without  delay.  A  general  anaesthetic,  especially 
chloroform,  is  to  be  avoided  if  possible,  local  or  spinal  anaesthesia  being  preferred. 
Strict  asepsis  is  of  the  greatest  importance  :  the  mortality  of  aseptic  operations, 
in  Karewski's  experience,  amounted  to  I4'7  per  cent,  that  of  septic  operations  to 
26  per  cent ;  ti-8  of  the  former  and  21-7  of  the  latter  being  due  to  coma.  Shock 
is  also  to  be  avoided  by  all  possible  means,  and  it  is  wise  to  reduce  the  glycosuria 


I50 


INDEX     OF     PROGNOSIS 


by  diet,   and  to    administer  doses    of   bicarbonate  of   soda,   before  operation. 
Acetonuria  is  a  contra-indication  to  surgical  interference. 

Mode  of  Death. — The  greater  number  of  diabetics  die  ultimately  from  coma, 
this  condition  occurring  in  probably  90  per  cent  of  the  acute  cases.  In  chronic 
diabetes  this  termination  is  less  common,  but  can  never  be  excluded.  The 
next  most  common  cause  of  death  is  tuberculosis  of  the  lungs,  which  is  also  more 
frequent  in  young  subjects  with  severe  disease.  Other  causes  of  death  are  septic 
infection,  as  from  carbuncle  or  erysipelas,  cerebral  hasmorrhage,  uraemia  as  a 
sequel  to  albuminuria,  gradual  cardiac  failure  of  arteriosclerotic  type,  and  a 
peculiar  form  of  sudden,  or  almost  sudden,  cardiac  failure,  possibly  due  to  involve- 
ment of  the  myocardium.  In  some  cases  in  which  the  symptoms  of  coma  are 
present,  the  patient,  nevertheless,  retains  actual  consciousness  until  the  end. 

References. — Eaton  and  Woods,  Arch,  of  Pediat.  191 1,  xxvii,  905  ;  Feilchenfeld, 
Zeitschr.  /.  V ersicherungsmed.  1912,  v,  33  ;  Franck,  Arch.  f.  experim.  Pathol.  1913, 
Ixxii,  387  ;  Laache,  Med.  Klin.  1910,  vi,  503  :  Lapersonne,  Presse  Med.  1910,  xviii,  89  ; 
Karewski,  Deut.  med.  Woch.  1914,  No.  i  ;  Whitridge  WilHams,  Amer.  Jour.  Med.  Set. 
1909,  cxxxvii,  I  ;   WUliamson,  Practitioner,  1911,  Ixxxvi,  821.  iy_  Cecil  Bosanquet. 

DIARRHCEA,  INFANTILE. — Simple  non-inflammatory  diarrhaea  is  very  much 
less  serious  than  inflammatory  diarrhoea  due  to  enterocolitis.  In  this  latter 
condition,  high  fever,  constant  vomiting,  marked  tenesmus,  loss  of  elasticity 
of  the  skin,  drowsiness,  collapse,  grave  nervous  symptoms  associated  with 
convulsions,  are  to  be  regarded  as  of  the  greatest  gravity. 

Pulmonary  catarrh  with  collapse  of  alveoli,  and  bronchopneumonia  not 
infrequently  arise  during  the  iUness,  rendering  the  outlook  still  more  serious. 
If  the  temperature  in  the  rectum  reaches  105°  the  prognosis  is  verj^  bad,  or 
if  it  runs  up  with  a  sudden  leap  from  the  normal  to  any  great  height.  Exposure 
to  chiU  during  the  height  of  the  attack  is  very  likely  to  produce  an  exacerbation 
of  all  the  symptoms. 

Summer  Diarrhoea  (Cholera  Infantum). — In  this  complaint  the  prognosis  is 
based  on  points  similar  to  those  mentioned  above  (enterocolitis).  The  younger 
the  patient  (ceteris  paribus),  the  worse  the  prognosis. 

In  the  more  chronic  diarrhoeas  of  children,  the  incidence  of  oedema  of  the 
extremities  is  a  sign  of  grave  import,  and  so  also  is  the  onset  of  thrush  in  the 
mouth.  J.  ij.  Charles. 

DILATATION  OF  THE  STOMACH.— (See  Stomach,  Medical  Affections  of.) 

DIPHTHERIA. — The  most  important  factors  which  govern  the  prognosis 
of  this  disease  are  :  (i)  The  age  of  the  patient ;  (2)  The  site  of  the  disease  ; 
(3)  The  severity  of  the  attack  ;  (4)  The  occurrence  of  certain  complications  ; 
(5)   The  treatment. 

I.  Age  of  Patient. — The  following  table,  based  on  56,507  cases  of  diphtheria 
treated  in  the  hospitals  of  the  Metropolitan  Asylums  Board  during  the  years 
1900  to  1909,  shows  the  importance  of  age  as  a  factor  in  the  case-mortality: — 

Fatality  according  to  Age. 


Fatality 

Fatality 

Fatality 

per  cent 

per  cent 

per  cent 

0-1 

34-0 

0-5 

15-7 

25-30 

1-3 

1-2 

22-7 

5-10 

8-3 

3i-35 

1-3 

2-3 

16-4 

10-15 

34 

35-40 

4  0 

3-4 

13-4 

15-20 

1-8     ; 

40  and  over 

5  0 

4-5 

]]-2 

20-25 

0-9 

All  ages 

10-3 

DIPHTHERIA  151 

From  ttiis  table  it  appears  that  the  disease  is  much  more  fatal  in  children  than 
in  adults;  and  that,  up  to  twenty -five  years  of  age,  the  younger  the  patient 
the  greater  is  the  risk  to  hfe.  The  large  majority  of  these  patients  were  treated 
with  antitoxin: 

2.  Site  of  the  Disease. — The  most  common  sites  are  the  fauces,  nasal 
passages,  and  lavynx.  The  false  membrane  may  be  found  on  all  these  parts 
simultaneously,  or  may  be  limited  to  one  of  them.  The  more  intimately  adherent 
the  false  membrane  is  to  the  mucous  surface,  the  more  surely  will  absorption  of 
toxin  take  place  and  toxaemia  and  its  sequels  occur.  Now  the  false  membrane 
is  almost  invariably  attached  very  loosely  to  the  nasal  passages  and  to  the  larynx 
and  trachea.  Hence,  toxaemia  is  seldom  pronounced  and  is  often  absent  in 
nasal  and  laryngeal  diphtheria  if  the  fauces  are  unaffected  ;  and  it  is  the  faucial 
form  of  the  disease  which  affords  the  most  striking  examples  of  toxaemia. 
Diphtheria  of  the  air-passages  is,  however,  the  most  fatal  of  the  three  varieties 
under  discussion,  because  of  the  mechanical  obstruction  to  respiration  to  which 
it  gives  rise  by  the  occlusion  of  the  larynx,  trachea,  or  bronchi.  Simple  nasal 
diphtheria  is  seldom  fatal.  The  most  serious  cases  are  those  in  which  the  nose, 
throat,  and  windpipe  are  simultaneously  involved. 

An  estimate  of  the  influence  on  prognosis  of  the  involvement  of  the  larynx 
may  be  derived  from  the  statistics  of  the  Asylums  Board  already  quoted.  During 
the  ten  years  1900  to  1909,  the  fatality  of  cases  in  which  the  larynx  was  not 
affected  was  8-8  per  cent;  whereas  in  those  in  which  it  was  affected  (with  or 
without  involvement  of  the  fauces)  the  fatality  was  18-9  per  cent. 

Of  other  forms  of  diphtheria,  the  vulval  and  cutaneous  are  the  most  serious, 
because  they  are  prone  to  be  accompanied  by  grave  toxaemia.  In  ocular  diph- 
theria there  is  considerable  risk  of  loss  or  impairment  of  sight  from  damage  to  the 
eyeball. 

3.  Severity  of  the  Attack. — Most  laryngeal  cases  must  be  regarded  as  severe, 
because  of  the  high  fatality  amongst  them.  Nearly  half  of  them  come  to 
tracheotomy  or  intubation. 

In  other  forms  of  the  disease,  severity  depends  upon  the  degree  of  toxemia : 
this,  in  its  turn,  depends  upon  the  extent  and  persistence  of  the  false  membrane. 
Albuminuria  may  be  taken  as  a  rough  index  of  toxaemia  ;  the  more  lasting  the 
albumin  and  the  larger  its  amount,  the  more  profound  the  toxaemia  and  the 
greater  the  chance  of  the  occurrence  of  some  untoward  event.  Early  nephritis 
(blood  and  casts  in  the  urine)  is  a  most  serious  condition  :  fortunately,  it  is  rare. 
The  following  symptoms  of  toxaemia  are  extremely  grave  :  repeated  vomiting  ; 
scantiness  of  urine  ;  haemorrhages  into  the  skin  and  subcutaneous  tissue,  and 
also  from  mucous  membranes  (unless  from  the  nose  only,  in  nasal  diphtheria)  ; 
an  infrequent,  feeble,  and  irregular  pulse  ;  an  ashen  hue  of  the  lips  and  extreme 
pallor.  In  most  cases  in  which  one  or  more  of  these  symptoms  are  present  the 
patient  is  evidently  ill,  even  to  the  unpractised  eye  ;  but  occasionally,  when 
there  is  progressive  suppression  of  urine,  with  little  or  no  vomiting,  he  may  seem 
to  be  doing  well,  and  even  to  be  getting  better.  Other  unfavourable  symptoms 
are  a  blotchy  erythematous  rash,  usually  most  pronounced  on  the  extremities  : 
enlargement  of  the  liver  ;    and  convulsions. 

4.  Complications. — Paralysis  is  the  most  frequent,  as  well  as  the  most  impor- 
tant, and  occurs  in  about  16  per  cent  of  the  cases.  It  usually  supervenes  after 
the  false  membrane  has  disappeared,  and  when  the  patient  may  appear  to  have 
recovered  from  the  attack  of  diphtheria.  Hence  it  is  important  to  know  what 
forms  of  diphtheria  it  may  follow.  The  lesions  which  give  rise  to  paralysis  are 
caused  by  the  toxin  ;  so  that  the  more  to.xic  the  case,  the  higher  the  risk  of  palsy. 
In  respect  of  the  gravity  of  the  paralysis  itself,  a  fatal  issue  is  the  more  to  be 


152  INDEX     OF     PROGNOSIS 

feared  the  earlier  this  compUcation  arises  and  the  more  rapidly  the  various  groups 
of  muscles  are  involved.  The  outlook  is  grave  if  anj^  of  the  ordinan'  muscles  of 
respiration  are  affected,  especially  the  diaphragm.  Frequent  vomiting  is  a 
serious  sj^mptom.  Paralysis  is  met  with  much  more  often  in  children  than  adults. 
Its  termination  is  either  by  complete  recovery  or  by  death  ;  patients  are  never 
left  permanently  paralyzed.     About  13  per  cent  of  the  cases  are  fatal. 

Heart  Failure  may  occur,  not  onlj'  in  connection  ■\\dth  paralysis,  but  even  in 
cases  in  which  that  complication  has  not  supervened.  Like  palsy,  it  is  to  be 
anticipated  most  in  the  toxic  form  of  the  disease.  Acute  cardiac  dilatation, 
especially  when  accompanied  by  precordial  pain,  is  nearly  alwaj-s  fatal.  Heart 
failure  is  prone  to  occur  in  patients  who  have  been  allowed  to  get  up  and  about 
too  soon  after  the  false  membrane  has  disappeared. 

Lobular  pneumonia  is  the  only  other  serious  compHcation.  It  is  found  only 
in  I  or  2  per  cent  of  the  cases,  and  chiefly  in  those  which  have  undergone 
tracheotomy. 

5.  Treatment.  Antitoxin. — In  cases  not  treated  with  antitoxic  serum  the 
prognosis  is  less  favourable,  ceteris  paribus,  than  in  those  so  treated.  Amongst 
the  antitoxin  treated  cases,  those  do  best  which  are  brought  under  treatment 
earliest.  Of  severe  cases  which  receive  the  serum  late,  those  have  the  best 
chance  of  recovery  in  which  large  doses  (20,000  to  30,000  units)  are  given.  The 
earlier  the  serum  treatment  is  commenced,  the  less  chance  is  there  of  the  larynx 
becoming  invaded,  and  of  paralysis  supervening.  If  paralj-sis  does  occur  in  a 
patient  who  has  been  treated  with  serum  early,  it  is  almost  always  very  sUght. 
Convalescence  is  hastened  in  those  who  receive  serum  treatment  at  the  begin- 
ning of  the  iUness. 

The  following  figures,  from  the  191 1  annual  report  of  the  Metropolitan 
Asylums  Board,  show  the  case-mortalit\'-  per  cent  according  to  the  day  of  disease 
upon  which  the  serum  treatment  was  commenced. 

Fatality  according  to  day  of  Commencement 
OF  Serum  Treatment. 


1 

Cases 

Deaths 

Fatality 
per  cent  . 

1st  dav  - 

149 

4 

2-6 

2nd    „     - 

- 

911 

31 

3-4 

3rd    „     - 

-• 

981 

88 

8-9 

4th     ,,     - 

- 

707 

89 

12-5 

5th    „  and 

over 

1 

1116 

150 

13-4 

Total 

3864 

362 

9-3 

Operation  (Tracheotomy  and  Intubation). — In  respect  of  recovery  after  tracheo- 
tomy, the  prospect  has  very  much  improved  since  the  introduction  of  the 
serum  treatment.  \Vhereas  about  30  per  cent  used  to  recover,  about  70  per 
cent  are  now  cured.  In  some  hospitals  intubation  is  practised,  usually  to  the 
partial  exclusion  of  tracheotomy.  It  is  impossible  to  compare  satisfactorily 
the  results  of  intubation  with  those  of  tracheotomy,  because  of  the  lack  of 
parallel  series  of  cases  which  can  be  fairly  set  against  each  other.  During  the 
seven  years  1905  to  1911,  436  cases  of  larjmgeal  diphtheria  were  submitted  to 
operation  at  the  Eastern  Hospital,  and  of  these  118  died,  a  fatality  of  27  per 
cent.     These  cases  can  be  arranged  as  follows  : — 


DISSEMINATED     SCLEROSIS 


153 


Fatality  after  Operation. 


Operation 

Cases 

Deaths             Fatality 
1      per  cent 

Intubation  only 
Intubation    followed 
by    tracheotomy 
Tracheotomy  only 

217 

102 

117 

19 

48 
51 

8-7 
47-0 
43-5 

Total 

436 

118 

27  0 

It  will  be  seen  that  31 'g  per  cent  of  the  intubated  cases  came  to  tracheotomy. 
The  fatality  of  all  the  cases  operated  upon,  viz.,  27  per  cent,  compares  favour- 
ably with  the  fatalit}^  about  30  per  cent,  of  the  tracheotomy  cases  at  those 
hospitals  in  which  intubation  was  not  practised. 

The  patient  who  is  intubated  recovers  much  more  quickly  than  the  patient 
who  is  submitted  to  tracheotomy. 

If  a  patient  is  intolerant  of  the  intubation  tube,  and  coughs  it  out  frequently, 
tracheotomy  should  be  performed  :  irritability  of  the  larynx  is  prone  to  be 
followed  by  ulceration.  But  if  membrane  is  coughed  out  with  the  tube,  even 
though  the  latter  is  frequently  expelled,  resort  should  still  be  had  to  re-intubation 
until  the  membrane  has  disappeared.  The  longer  the  intubation  tube  is  worn, 
the  more  likely  is  ulceration  of  the  larynx  to  be  set  up.  At  the  Eastern  Hospital 
an  intubation  tube  is  seldom  left  in  the  larynx  for  more  than  twelve  days  ; 
consequently  ulceration  of  the  larj^nx  is  seldom  met  with.  e.  W.  Goodall. 


DISLOCATIONS. — {See  Joints,  Injuries  of.) 

DISSEMINATED  SCLEROSIS. — The  causation  of  this  disease  is  undetermined 
as  yet.  The  characteristic  patches  of  sclerotic  overgrowth  of  glia  are  secondary 
to  an  antecedent  degeneration  of  the  medullary  sheaths.  Why  the  medullary 
sheaths  themselves  should  become  degenerate  is  at  present  unknown.  There  is 
much,  to  be  said  in  favour  of  a  toxic  origin  for  the  malady,  but  until  the  toxin 
is  actually  identified,  our  treatment  must  remain  frankly  symptomatic. 

Early  diagnosis  is  of  great  importance.  If  we  can  recognize  the  disease  in  its 
earliest  stage,  we  save  the  patient  from  misdirected  treatment.  Thus,  for 
example,  some  cases  of  disseminated  sclerosis  are  mistaken  for  cerebrospinal 
syphilis,  and  are  subjected  to  long  and  futile  courses  of  antisyphilitic  medication. 
Others  are  mistaken  for  tabes  or  other  varieties  of  ataxia.  Others,  again, 
mistaken  for  cerebellar  or  cerebral  tumour,  have  even  been  submitted  to  explora- 
tory operations.  Most  frequently  of  all,  the  remittent  course  of  disseminated 
sclerosis  causes  it  to  be  mistaken  for  hysteria  ;  and  the  patient  is  consequent!}' 
stimulated  by  encouraging  suggestions  to  try  and  '  throw  off  '  her  malady  by 
an  effort  of  will,  and  to  undertake  exercises  of  a  fatiguing  kind  which  probably 
hasten  the  progress  of  the  disorder. 

The  duration  of  the  disease  is  uncertain.  At  the  outset  it  should  be  remem- 
bered that,  by  itself,  it  is  rarely  fatal.  The  commonest  course  is  a  chronic  one 
lasting  for  years,  with  occasional  periods  of  remissions  or  arrest,  during  which 
marked  improvement  takes  place,  followed,  after  variable  intervals,  by  further 
relapses.  The  remissions  may  amount  to  apparent  cure.  The  longest  remission 
with  which  I  am  acquainted  occurred  in  the  case  of  a  woman  who,  at  the  age  of 
twenty-three,  had   her  first   symptoms   of   the   disease,    consisting  in   complete 


154  INDEX    OF    PROGNOSIS 

paraplegia,  with  loss  of  sphincter  control,  and  with  central  scotoma  due  to  retro- 
bulbar neuritis  ;  she  recovered  from  this  in  six  months.  Three  years  later,  she 
had  another  attack  of  visual  trouble,  with  weakness  of  the  right  leg,  lasting 
several  months.  She  married  at  the  age  of  twenty-nine  and  had  four  healthy 
children.  For  many  years  she  led  an  active  life,  apparently  in  ordinary  health. 
At  the  age  of  fifty-three — i.e.,  twenty-seven  years  after  her  second  attack, — she 
again  became  weak  in  the  right  leg,  and  within  three  years  developed  the  classical 
signs  of  disseminated  sclerosis,  including  motor  weakness,  intention  tremors, 
and  the  characteristic  changes  in  the  reflexes.  At  the  age  of  sixty-eight — i.e. 
forty-five  years  after  the  first  onset  of  the  disease, — she  is  still  alive,  although  the 
limbs  are  severely  paralyzed  and  ataxic.  Nevertheless  she  gets  up  to  dinner 
daily,  and  is  still  able  to  go  out  driving. 

The  next  most  common  variety  of  the  disease  is  that  in  which  the  symptoms, 
after  slowly  or  rapidly  attaining  a  degree  of  moderate  severity,  remain  more  or 
less  stationary.  The  patient,  although  suffering  from  motor  weakness  and 
perhaps  confined  to  bed,  remains  well-nourished  ;  and  the  general  health  is  fairly 
well  sustained,  it  may  be  for  many  years,  until  at  last  a  final  exacerbation  of  the 
disease  occurs. 

A  third  variety  is  met  with,  where  the  patient  has  a  series  of  attacks  or  exacerba- 
tions, consisting  in  transient  blindness,  diplopia,  monoplegic  or  hemiplegic 
attacks,  etc.,  clearing  up  in  part,  but  leaving  him  in  the  intervals  more  and  more 
paralyzed,  each  fresh  exacerbation  lowering  the  general  level  of  strength,  until 
the  patient  becomes  bedridden,  with  contractures,  sphincter  trouble,  etc.  In 
such  cases,  careful  attention  is  required  to  prevent  cystitis  and  bed-sores,  either 
of  which  complications  may  lead  to  a  terminal  toxaemia.  Intercurrent  pulmonarj- 
complications,  tuberculous  or  pneumonic,  may  also  prove  fatal.  Bulbar  para- 
lysis, from  the  presence  of  a  sclerotic  area  in  the  medulla,  is  a  less  common  cause 
of  death. 

To  sum  up,  then,  the  prognosis  in  disseminated  sclerosis,  as  regards  cure,  is 
unfavourable  ;  but,  as  regards  duration,  long  remissions  may  occur,  especially 
if  the  patient  avoids  physical  or  mental  strain.  In  the  later  stages,  when  the 
patient  has  become  bedridden,  the  duration  of  life  depends  on  assiduous  nursing, 
the  prevention  of  bed-sores  and  of  bladder  infection,  and  the  avoidance  of 
pulmonary  and  other  complications. 

The  patient  with  disseminated  sclerosis  is  not  infrequently  somewhat  emotional, 
"with  a  tendency  to  smile  and  laugh  on  slight  provocation ;  but  in  uncomplicated 
cases  there  is  rarely,  if  ever,  any  true  intellectual  deficiency.  This  fact  is  some- 
times of  importance  with  regard  to  testamentary  capacity.  Purves  Stewart. 

DRUG  HABITS. — [See  also  Mental  Diseases.) 

Opium. — Children  are  much  more  susceptible  to  the  influence  of  opium  than 
adults,  but  among  the  latter  there  is  a  very  great  personal  factor  as  far  as 
susceptibility  is  concerned.  In  acute  poisoning,  a  cyanotic  or  ashy  face  covered 
with  clammy  sweat  is  of  extremely  grave,  but  not  necessarily  fatal,  significance. 
It  should  be  remembered  that  in  the  comatose  condition,  false  appearances  of 
improvement  may  occur  which  are  very  deceptive,  the  patient  again  relapsing 
into  a  fatal  coma.  Since  death  generally  supervenes  as  the  result  of  failure  of 
respiration,  an  improvement  in  the  depth  of  this,  and  in  the  colour  of  the  skin, 
should  be  carefully  looked  for.  Dilatation  of  the  pupils,  during  deep  coma, 
following  on  their  contraction,  is  of  the  gravest  import. 

Morphia. — In  morphinism,  much  depends  on  the  length  of  time  the  patient 
has  been  under  the  influence  of  the  drug,  and  the  dose  taken.  As  much  as 
75  gr.  has  been  tolerated  by  chronic  morphinomaniacs  in  the  course  of  twenty- 


DRUG     HABITS  155 


four  hours.  It  is  probably  more  difficult  to  break  the  habit  in  patients  who 
take  the  drug  hypodermically,  than  in  those  who  take  it  in  any  other  way.  As 
in  opium-eating,  there  is  a  very  marked  personal  element  in  the  amount  which 
can  be  tolerated.  Young  people  can  stand  larger  doses  over  more  prolonged 
periods  without  gross  cachexia  appearing  than  can  the  more  elderly.  The  latter 
are  more  liable  to  feel  the  effects  of  the  withdrawal  of  the  drug  in  a  greater 
degree.  Chronic  morphinomaniacs  do  not  live  to  an  old  age  and  are  very  liable 
to  be  carried  off  by  an  attack  of  some  relatively  mild  acute  disease  ;  or  if  they 
escape  this,  they  pass  into  a  condition  of  extreme  asthenia  and  emaciation,  and 
die  from  sheer  bodily  debility. 

During  treatment,  the  great  danger  is  that  of  inducing  a  fatal  collapse  by 
too  sudden  withdrawal  of  the  drug,  while  there  are  frequently  periods,  after 
cure  has  been  apparently  obtained,  during  which  the  patient  suffers  from 
intense  craving  for  morphia  ;  the  craving  is  less  severe  and  not  so  constantly 
repeated  as  in  the  case  of  alcoholism  or  cocainism.  These  periods  of  craving 
may,  however,  recur  for  eighteen  months  to. two  years  after  the  cure. 

Heroin. — This  is  not  a  harmless  drug,  for  a  habit  may  be  induced  which, 
in  severe  cases,  presents  as  much  difficulty  in  escaping  from  as  does  the 
escape  from  the  opium  habit.  Moreover,  the  patients  may  remain  physical 
wrecks,  with  undermined  constitutions  and  of  no  resisting  power,  even  when 
they  have  been  cured  of  their  habit. 

Cocaine. — The  prognosis  of  chronic  cocainism  is  worse  than  in  the  case  of 
morphinism,  because  the  patients  have  no  desire  whatever,  in  the  great  majority 
of  cases,  to  be  delivered  from  their  habits,  and  have  a  very  great  tendency  to 
relapse  immediately  they  are  liberated  from  restraint.  There  is  a  greater 
destruction  of  the  higher  mental  faculties  than  in  the  case  of  morphinism,  and, 
if  possible,  the  patients  are  even  more  inveterate  liars. 

This  renders  treatment  more  difficult  and  prognosis  worse.  With  the  onset 
of  marked  emaciation,  sunken  eyes,  tremors,  hallucinations,  and  delusions  of 
persecution,  the  prognosis  is  well-nigh  hopeless.  It  produces  destruction  of 
its  victim  more  quickly  than  opium  or  alcohol.  Delusional  insanity  may  develop 
very  rapidly  in  chronic  cocainism,  and  the  delusions  may  remain  for  weeks 
after  the  drug  has  been  entirely  withdrawn.  There  is  a  strong  personal  idio- 
syncrasy to  the  effects  of  the  drug. 

Chloral. — Full  tolerance  is  not  obtained  even  though  the  habit  of  taking 
this  substance  may  have  lasted  for  a  long  time.  The  great  importance  of  this 
is  that  the  usual  dose,  or  even  a  smaller  dose  than  usual,  may  be  followed  by 
a  fatal  result.     The  same  remark  holds  good  with  reference  to  chloroform. 

Sulphonal. — The  repeated  ingestion  of  sulphonal  may  lead  to  very  serious 
symptoms,  because  the  drug  has  a  cumulative  action,  being  excreted  slowly 
from  the  body.  A  dangerous  sign  is  the  onset  of  ha^matoporphyrinuria, 
evidenced  by  the  appearance  of  red,  pink,  brown,  or  almost  black  urine.  This 
danger  is  more  marked  in  women  than  in  men.  When  given  continuously, 
sulphonal  may  produce  sudden  coma  and  death,  but  more  often  there  are  other 
warning  symptoms  such  as  hallucinations,  mental  confusion,  exhaustion,  nausea, 
tympanites,  abdominal  pain,  cyanosis,  coldness  of  the  extremities.  These  may 
be  followed  by  death  from  exhaustion  in  some  cases. 

If  any  of  these  symptoms  arise,  the  use  of  the  drug  must  be  immediately 
suspended ;  but  all  danger  is  not  then  passed.  Serious  symptoms  have  arisen 
for  the  first  time  as  long  as  nine  days  after  the  cessation  of  the  administration 
of  the  drug. 

Trional  and  Tetronal  may  produce  the  same  grouping  of  symptoms,  including 
lijematoporphyrinuria,  if  given  over  a  prolonged  period.     A  large  single  dose  is 


156  INDEX     OF     PROGNOSIS 

not  likely  to  produce  them,  as  much  as  120  gr.  of  trional  having  been  taken 
without  the  onset  of  hasmatoporphyrinuria.  /.  r.  Charles. 

DUODENAL  ULCER  (see  also  Stomach,  Surgical  Affections  of). — 
Remembering  that  in  many  cases  an  ulcer  of  the  duodenum  is  entirely  latent 
as  far  as  any  manifestation  is  concerned,  it  is  impossible  to  say  how  many  get 
well  unrecognized.  Of  those  diagnosed,  perforation  is  stated  to  occur  in  about 
40  per  cent,  while  more  or  less  severe  haemorrhage  arises  in  from  30  to  40  per 
cent.  In  different  series  the  mortality -rate  from  haemorrhage  has  varied  from 
13  up  to  36  per  cent.  The  possibility  of  complications,  which  include  abscess 
(e.g.,  subphrenic),  subsequent  stenosis  of  the  duodenum,  stenosis  of  the  common 
bile-duct,  and  secondary  malignant  disease,  must  be  borne  in  mind  in  giving 
a  prognosis.  Relapses  in  duodenal  ulcer  occur  with  about  the  same  frequency 
as  in  gastric  ulcer.  /.  r   Charles  . 

DYSENTERY.— (5ee  also  Colitis.) 

Bacillary  Form. — A  group  of  many  closely-allied  bacilli,  and  some  other 
bacilli  not  belonging  to  the  group,  are  capable  of  causing  dysentery,  often  in  an 
epidemic  form.  Some  outbreaks,  particularly  those  in  Indian  prisons,  are 
attended  with  a  low  case-mortality,  2  per  cent  or  less,  and  the  fatal  cases  occur 
mainly  in  debilitated  persons  or  those  suffering  from  chronic  diseases  ;  when, 
however,  the  disease  assumes  a  chronic  form,  a  much  worse  prognosis  has  to  be 
given.  In  other  outbreaks,  as  those  in  camps  in  war,  in  asylums,  and  on  board 
ship,  the  prognosis  is  unfavourable  ;  50  to  80  per  cent  of  the  cases  in  some  small 
outbreaks  have  terminated  fatally,  and  a  mortality  of  20  per  cent  is  common. 
In  the  war  between  Japan  and  China  in  1894,  there  were  among  the  Japanese 
155,104  cases  of  dysentery  with  38,094  deaths,  or  a  mortality  of  24-5  per  cent, 
but  many  of  these  were  complicated  by  beri-beri.^ 

Amoebic  Form. — This  form  also  varies  greatly.  It  usually  runs  a  chronic 
recurrent  course  lasting  for  years,  but  may  be  an  acute  febrile  disease.  The 
prognosis  depends  on  the  severity  and  duration  of  the  disease,  or  on  complica- 
tions ;  the  complication  of  most  importance  is  acute  hepatitis  followed  by  liver 
abscess. 

The  introduction  of  the  treatment  by  salts  of  emetine  has  modified  the  prognosis 
both  of  the  disease  itself  and  the  liability  to  liver  abscess,  and,  after  the  occur- 
rence of  liver  abscess,  of  the  mortality.  Ipecacuanha  as  given  previously  had 
a  similar  effect,  but  the  equivalent  doses  could  not  be  tolerated,  and  therefore 
both  the  number  of  cases  and  the  results  were  less  marked.  By  the  use  of 
either  preparation  a  smaller  proportion  of  cases  of  hepatitis  go  on  to  abscess- 
formation. 

When  an  abscess  has  formed,  it  may  burst  naturally :  into  or  through  the 
lungs,  when  about  50  per  cent  recover  ;  or  into  the  intestine,  with  a  similar 
result ;  if  it  opens  into  the  pleura  or  peritoneum,  even  when  operated  on,  the 
prognosis  is  more  unfavourable.  When  an  abscess  is  diagnosed  and  operated 
on,  if  it  can  be  evacuated  below  the  ribs  the  prognosis  is  more  favourable  than  if 
the  opening  has  to  be  made  through  the  chest  wall. 

The  mortality,  including  all  cases  and  various  methods  of  treatment,  varies 
between  10  and  20  per  cent,  but  no  doubt  with  the  free  use  of  emetine  better 
results  will  be  obtained. 

Davidson  gives  the  mortality  in  the  Indian  Army,  in  1901-3,  as  286  out  of 
522  cases.  C.  W.  Daniels- 

Reference. — ^Sandwith,  Lancet.  1914,  Sept.  5,  et  seq. 


DYSMENORRHCEA  157 


DYSMENORRH(EA. 

I.  Spasmodic. — This  variety  is  the  commonest,  and  in  many  ways  the  most 
troublesome.  Great  difficulty  is  experienced  in  giving  an  opinion  as  to  the 
evolution  of  a  case  of  spasmodic  dysmenorrhoea. 

There  are  three  points  upon  which  the  attention  should  be  focussed  :  [a]  The 
severity  of  the  symptoms  ;  (6)  The  physical  development  and  tone  ;  (c)  The 
neurotic  elem^ent. 

a.  The  Severity  of  Symptoms. — This  must  be  gauged  not  only  by  subjective 
impressions,  but  also  by  an  attempt  to  fix  by  other  means  the  standards  of 
expression  of  pain  peculiar  to  the  patient. 

In  cases  where  the  pain  is  severe,  localized  exactly  in  the  hypogastrium,  and 
lasts  for  a  day  or  two  with  definite  paroxysms,  it  is  usually  a  waste  of  time  to 
employ  medicines  ;  on  the  other  hand,  where  the  symptoms  do  not  appear 
intense,  and  the  other  features  are  good,  it  may  be  taken  that  in  the  majority 
of  cases  simple  medical  remedies,  attention  to  physical  hygiene,  and  sufficient 
rest,  will  be  successful. 

b.  Physical  Development  and  Tone. — In  the  first  place,  dysmenorrhoea  in  the 
small  infantile,  or  in  the  bicornuate,  uterus  is  almost  intractable  to  medical 
or  lesser  surgical  measures  (such  as  dilatation,  which  brings  at  most  only 
temporary  relief).     In  the  majority  of  cases  an  extirpation  is  eventually  required. 

Next,  in  cases  with  a  conical  cervix  or  with  anteflexion,  the  results  of  medical 
treatment  are  small,  while  dilatation  or  incision  of  the  cervix  is  permanently 
successful  in  at  least  50  per  cent  of  the  cases,  and  in  many  more  for  a  period 
of  from  one  to  five  years.  The  failures  are  in  many  cases  explained  by  faulty 
operation,  in  which  the  internal  os  escaped  dilatation.  Older  gynaecologists 
are  agreed  that  the  use  of  the  glass  stem  enhances  the  chance  of  cure  in  cases  of 
anteflexion. 

In  those  cases  in  which  there  is  no  physical  defect,  attention  should  be  paid 
to  the  general  tone  of  the  body  ;  many  patients  in  weak  health,  physicalljr 
exhausted  and  anasmic,  only  require  judicious  correction  of  errors,  and  medical 
measures,  in  order  to  recover  completely. 

c.  The  Neurotic  Element. — The  greatest  difficulty  will  be  found  in  estimating 
the  proportion  due  to  an  underlying  neurosis,  and  that  due  to  the  effect  of 
continued  dysmenorrhoea.  The  patients  are  usually  thin,  often  the  subjects  of 
chronic  arthritis  and  bad  circulation. 

There  is  no  doubt  that  the  continued  pain  endured  for  years  leads  eventually 
to  a  lowered  resistance,  and  a  morbid  fear  of  the  forthcoming  period,  while  relief 
is  often  found  in  alcohol,  or  in  morphia  injections.  Under  these  circumstances 
it  is  rare  for  medical  treatment  alone  to  be  successful,  and  cervical  operations 
give  as  a  rule  but  a  temporary  benefit. 

Reviewing,  then,  the  prognosis  of  spasmodic  dysmenorrhosa  in  general,  it  is 
seen  that  the  greatest  circumspection  is  required  in  forming  an  opinion.  Beyond 
the  special  points  detailed  above,  other  factors  are  the  age  of  the  patient  and 
the  presence  of  sterility.  Sterility  is  an  indication  for  dilatation — and  the 
results  are  perhaps  best  expressed  in  the  following  figures  given  by  Brickner^: 
Of  38  patients  suffering  from  dysmenorrhoea  and  sterility,  only  27  per  cent  were 
cured  of  both  the  sterility  and  the  dysmenorrhoea. 

The  following  figures  also  give  some  indication  of  the  outlook  in  dysmenorrhoea 
generally.  Findley-  quotes  Kelly  as  follows  :  Of  95  cases  of  dilatation,  18,  or 
19  per  cent,  were  permanently  relieved  ;  14,  or  i^-j  per  cent,  received  great 
benefit ;  and  7,  or  7-4  per  cent,  were  completely  relieved  for  from  one  to 
twelve  years,  when,  however,  the  pain  returned. 

Brickner^  used  Dudley's  operation  instead  of  dilatation  in  73  cases — 42  for 


158  INDEX    OF    PROGNOSIS 

dysmenorrhcea  alone,  and  38  for  dysmenorrhoea  with  sterility — and  obtained 
the  following  results  :  Of  the  42  patients  with  dysmenorrhoea,  64-3  per  cent 
were  relieved;  33-3  were  not  relieved;  and  2-4  per  cent  were  worse;  of  the  38 
patients  Avith  both  dysmenorrhoea  and  sterility,  27  per  cent  were  cured  of  both. 

2.  Membranous. — This  much  rarer  condition  is  decidedly  more  grave  in  out- 
look ;  it  has  not  been  successfully  treated  by  drugs,  and  it  nearly  always  recurs 
after  dilatation  and  curettage.  It  is  important  to  try  to  discover  the  presence 
of  any  pelvic  disease  ;  thus,  in  a  few  cases  operation  has  revealed  a  tuberculous 
condition  of  the  appendages,  associated  with  tuberculous  endometritis,  and 
hysterectomy  has  brought  permanent  relief. 

3.  Congestive. — This  covers  a  wide  field,  and  is  after  all  but  a  symptom  in 
the  course  of  pelvic  inflammatory  disease  or  uterine  displacement,  so  that  it 
rarely  requires  consideration  from  the  point  of  view  of  the  dysmenorrhoea. 
Nothing,  however,  is  more  striking  than  the  alleviation  of  the  symptoms 
which  results  from  the  correct  treatment  of  the  underlying  pathological  lesion. 

References. — ^Surg.  Gyn.  and  Obst.  1911,  ii,  Nov. ;   ^Diseases  of  Women,  1914,  51. 

Bryden  Glendining. 
EAR  DISEASE,  INTRACRANIAL  COMPLICATIONS  OF.— (See  Intracranial 
Complications  of  Ear  Disease.) 

ECLAMPSIA. 

Maternal  Prognosis. 

In  considering  the  prognosis  as  regards  the  mother  in  eclampsia,  it  is  necessary 
to  pay  special  attention  to  particular  symptoms,  and  it  is  only  at  a  comparatively 
late  stage  of  the  disease  that  it  is  possible  to  form  an  opinion. 

The  general  mortality  in  a  large  series  of  cases  will  be  found  to  range  round 
25  per  cent,  but  in  a  small  series  it  may  be  reduced  to  3  per  cent,  or  even  less. 
This  does  not  so  much  indicate  a  marked  superiority  of  one  form  of  treatment 
over  another  as  it  points  to  the  fact  that  the  cases  in  one  series  have  been  mild 
and  in  another  severe.  While  the  majority  of  obstetricians  are  convinced  that 
emptying  the  uterus  as  soon  as  convenient  after  the  first  convulsion  is  most 
important,  there  yet  remain  a  number  of  physicians,  especially  among  the 
senior  members  of  the  profession,  who  are  in  no  way  convinced  that  the  results 
therefrom  are  an  improvement  upon  the  purely  expectant  methods  of  treatment 
of  former  years.  Bumm^  believes  that  the  quicker  the  uterus  is  emptied  after 
the  onset  of  fits  the  better  the  results,  and  he  states  that  by  adopting  such  a 
principle  he  is  enabled  to  reduce  the  mortality  from  25  or  30  per  cent — repre- 
senting the  results  of  expectant  treatment — to  2  or  3  per  cent. 

The  Maternal  Prognosis  from  the  Clinical  Aspect. — The  prognosis  varies 
directly  with  the  period  of  onset  of  the  fits.  The  figures  compiled  by  Galabin^ 
from  the  records  of  the  Guy's  Charity  are  most  striking  in  this  respect :  In 
cases  beginning  before  the  onset  of  labour,  the  mortality  was  50  per  cent ;  in 
those  beginning  during  labour,  it  was  25  per  cent ;    after  delivery,  8  per  cent. 

The  number  of  fits  and  the  interval  between  each  fit  are  undoubtedly  of  im- 
portance. Rapidly  recurring  fits  in  which  the  interval  becomes  shorter  and 
shorter  will,  as  a  rule,  soon  end  in  coma.  Recovery  has  been  recorded  in  a  patient 
in  whom  200  convulsions  were  reported.  Some  idea  of  the  importance  of  the 
number  of  fits  may  be  gained  from  the  results  of  Csesarean  section  in  this  respect. 
Peterson^  records  that  in  cases  thus  operated  upon  after  i  to  5  fits,  the  mortality 
was  15  per  cent ;  while  in  those  operated  upon  after  6  fits  had  occurred,  it  was 
30-3  per  cent.  That  is  to  say,  after  the  fifth  fit  the  mortality  is  double.  It 
would  appear  that  the  administration  of  chloroform  or  chloral  has  in  many 
instances  been  of  service  in  reducing  the  number  of  fits. 


ECLAMPSIA  150 

The  function  of  the  urinary  system  is  of  the  greatest  importance  in  individual 
cases.  Grave  significance  attaches  to  a  marked  diminution  of  the  total  quantity 
of  urine'  excreted  in  the  twenty-four  hours — especially  when  the  small  quantity 
becomes  solid  with  albumin.  Conversely,  an  increase  in  the  daily  quantity 
of  urine  is  to  be  regarded  as  pointing  to  a  favourable  termination. 

Evidence  of  jaundice  following  the  eclamptic  convulsions  must  be  taken  to 
indicate  considerable  lesions  in  the  liver.  In  these  cases  there  is  frequently  a 
persistently  raised  temperature,  a  degree  or  two  above  normal,  and  a  prolonged 
stage  of  coma.  In  the  worst  cases  there  is  some  haematuria,  and  small  sub- 
cutaneous haemorrhages  are  seen. 

Deep  coma  accompanied  by  considerable  elevation  of  the  temperature  will 
probably  indicate  cerebral  lesions. 

Lastly,  a  point  which  is  often  overlooked,  but  which  is  of  importance  from 
the  point  of  view  of  prognosis,  is  the  fact  that  eclampsia  renders  the  patient 
liable  to  haemorrhage  during  parturition  and  to  septic  infection  during  the 
puerperium,  so  that  it  must  not  be  concluded  that  all  danger  is  past  because 
the  fits  have  ceased. 

The  Maternal  Prognosis  from  the  point  of  view  of  Treatment. — There  is 
little  doubt  that  injudicious  treatment  may  be  attended  with  disastrous  results. 

First,  with  regard  to  expectant  methods,  it  would  appear  inadvisable  to  persist 
in  them  if  labour  is  not  progressing  and  the  fits  continue.  They  are,  of  course, 
the  only  resource  in  post-partum  cases,  except  where  a  marked  drop  in  the 
urinary  excretion  renders  it  advisable  to  try  decapsulation  of  the  kidneys,  an 
operation  in  which  the  mortality  is  at  least  50  per  cent. 

In  the  vast  majority  of  cases,  the  problem  resolves  itself  into  deciding  which 
is  the  best  method  of  emptying  the  uterus  under  the  circumstances.  It  is 
generally  admitted  at  the  present  day  that  the  best  results  will  be  obtained  by 
that  method  in  which  the  uterus  is  most  rapidly  emptied  while  at  the  same 
time  the  patient  receives  the  least  shock.  It  is  assumed  that  emptying  the 
uterus  prevents  further  auto -intoxication  from  placental  bodies  ;  on  this 
assumption  it  is  a  priori  probable  that  the  best  results  would  follow  Csesarean 
section  in  all  cases  occurring  before  dilatation  of  the  cervix.  Unfortunately 
Caesarean  section  is  regarded  by  most  obstetricians  as  being  too  serious  a  pro- 
cedure except  in  special  circumstances,  and  it  must  be  admitted  that  the  results 
liitherto  have  not  been  strikingly  superior  to  those  given  by  more  conservative 
methods  ;  though  it  is  undoubtedly  true  that  the  figures  of  Caesarean  section 
represent  a  large  proportion  of  very  severe  cases. 

Three  methods  of  emptying  the  uterus  require  consideration  :  (i)  Rapid 
dilatation  of  the  cervix,  with  forceps  delivery  ;  (2)  Vaginal  Caesarean  section  ; 
(3)  Abdominal  Caesarean  section. 

1.  Rapid  dilatation  of  the  cervix  is  indicated  in  cases  about  terni,  in  which 
the  cervix  is  readily  dilatable.  The  results  of  this  method  of  treatment  have 
been  published  by  Bossi*  (who  uses  a  special  dilator),  the  maternal  mortality 
being  14  out  of  148  cases,  or  9-45  per  cent.  These  results  are  certainly  good. 
Bossi's  dilator  has  not  become  popular ^  however,  owing  to  the  risk  of  extensive 
laceration  of  the  cervix  ;  so  that  dilatation  with  the  hand  is  considered  to  be 
the  safer  method. 

2.  Vaginal  CcBsarean  section  has  given  results  which  have  not  been  uniformly 
good,  owing  to  the  fact  that  even  after  the  lower  segment  has  been  incised  it  still 
remains  to  extract  the  child.  Again,  unless  the  cervix  is  already  'taken  up,' 
the  difficulty  of  the  operation  may  be  considerable. 

Routh^  has  collected  15  cases  performed  by  British  operators,  with  7  deaths, 
a  mortality  of  26-6  per  cent.  Beckmann,^  however,  employing  this  method, 
has  a  mortality  of  18  per  cent. 


i6o 


INDEX     OF    PROGNOSIS 


3.  Abdominal  Ccesarean  section  has  been  more  extensively  performed.  It 
gives  the  best  results  in  cases  in  whicli  the  cervix  is  rigid  and  it  is  thought 
advisable  to  empty  the  uterus  at  once.  The  figures  of  results  varj^  considerably. 
Thus,  Routh^  collected  105  cases  by  British  operators,  and  found  that  there 
had  been  50  deaths,  a  mortality  of  47-6  per  cent ;  Peterson^  collected  283  cases 
from  all  over  Europe  and  America,  operated  upon  between  1908  and  1913,  and 
found  a  mortality  of  25-79  per  cent  ;  still  better  results  are  shown  in  91  cases 
operated  on  by  thirteen  different  surgeons — a  mortality,  namely,  of  18-63  P^r 
cent. 

FcETAL    Prognosis. 

The  later  the  onset  of  eclampsia  and  the  less  the  number  of  fits  that  occur, 
the  better  the  outlook  becomes  for  the  foetus. 

As  regards  treatment,  there  is  no  doubt  that  provided  the  child-  is  viable, 
abdominal  Caesarean  section  offers  a  very  much  better  prospect  than  an}^  other 
method.  Thus,  in  Peterson's^  statistics  of  248  cases,  when  only  the  viable 
children  were  taken  into  account,  the  foetal  mortality  was  9  per  cent. 

Lichtenstein,  in  the  Leipzic  Klinik,  grouping  all  methods  of  treatment,  had 
a  foetal  mortality  of  37-3  per  cent  in  94  cases;  or  counting  only  viable  children, 
21-3  per  cent.     Bossi*  gives  the  foetal  mortahty  in  148  cases  as  20-97  P^^  cent. 

References. — ^Bumm,  "  Die  Behandlung  der  Eklampsie,"  Dent.  med.  Woch.  1907, 
xxxiii,  1945-1947  ;  -Galabin  and  Blacker,  Midivifery,  485  ;  ^Peterson,  Arner.  Jour. 
Ohst.  1914,  AprU  ;  *Bossi,  16th  Intern.  Cong.  Med.  (Sect.  Obst.  et  Gyn.),  Buda-pest,  1909  ; 
^Routh;  Jour.  Obst.  and  Gyfi.  1911,  Jan.;    ^Beckm.d.nn,  Mo nats.  f.Geb.  u.  Gyn.  1913, 

""■  ^'  Bryden  Glendining. 

ECTOPIC  PREGNANCY. — The  prognosis  depends  upon  :  (i)  The  method  of 
ireatinent  adopted  ;  (2)  The  stage  of  advancement  of  the  pregnancy ;  and  (3) 
The    condition  of   the   patient   when   she    comes   tinder    observation. 

I.  The  Method  of  Treatment. — It  is  now  established  beyond  doubt  that  the 
best  results  are  attained  by  immediate  operation  in  all  cases  in  which  the  gesta- 
tion has  not  advanced  beyond  the  sixth  month.  The  late  Hamilton  Bell, 
investigating  cases  from  St.  Thomas's  Hospital,  observed  that  many  haematoceles 
due  to  ectopic  gestation  were  completely  absorbed,  if  left  alone  ;  this  is  generally 
admitted,  but  the  adoption  of  such  a  course  is  fraught  with  dangers  which  far 
outweigh  the  risks  of  surgical  interference.  The  immediate  dangers  are :  {a)  That 
a  further  and  possibly  fatal  haemorrhage  may  occur  ;  (6)  That  the  hematocele 
may  suppurate  ;  (c)  That  the  gestation  may  be  alive  and  secondarily  implanted 
in  the  pelvis,  when  the  surgeon  will  later  be  faced  by  the  problem  of  dealing 
with  an  ectopic  pregnancy  advanced  to  the  later  months.  Further,  there  are 
the  disabilities  that  certainly  accrue  from  the  palliative  treatment  of  ruptured 
ectopic  pregnancies,  in  that  adhesions  of  great  variety  and  density  are  almost 
certainly  formed. 

Some  idea  of  the  relative  value  of  the  two  methods  of  treatment  may  be 
gathered  from  the  following  table,  which  is  compiled  from  figures  given  by 
Findley-^  : — 

Treatment  of  Ectopic  Pregnancy. 


Author 

Treatment 

Cases 
241 

82 

130 

63 

Mortality 

Schauta     - 
Schauta 
Fehling 
Kronig 

Expectant 
Operative 

Do. 

Do. 

per  cent 

68-8 
2-4 
2-3 
0 

ECZEMA     AND     ECZEMATOUS    ERUPTIONS  i6i 

2.  The  Stage  of  Pregnancy. — The  surgical  difficulties  increase  with  the 
advancement  of  the  gestation.  Thus,  the  operation  is  relatively  simple  when 
undertaken  in  the  first  three  months.  From  thence  onwards  it  becomes  a 
more  formidable  procedure,  because  the  increased  size  of  the  placenta  and  of 
the  blood-vessels  passing  up  to  it,  of  necessity  gives  rise  to  profuse  haemorrhage 
during  its  removal.  So  much  is  this  the  case  in  the  later  months  of  gestation 
that  all  authorities  are  agreed  that  in  a  pregnancy  advanced  beyond  the  sixth 
month  it  is  wiser,  whenever  possible,  to  postpone  any  interference  until  after 
'  term  '  ;  at  this  epoch,  with  the  advent  of  spurious  labour  and  the  death  of 
the  foetus,  the  subsidence  of  the  placental  circulation  renders  the  removal  of 
the  foetus  and  the  separation  of  the  placenta  a  comparatively  innocuous  pro- 
ceeding, attended  by  inconsiderable  loss  of  blood. 

It  may,  however,  happen  that  the  surgeon  is  forced  to  intervene  during  the 
later  months  of  pregnancy,  either  by  reason  of  rupture  of  the  sac,  or  separation 
of  the  placenta,  causing  internal  haemorrhage.  The  risk  under  these  circum- 
stances is  always  considerable,  and  may  be  further  aggravated  by  the  site  of 
the  placental  implantation.  Thus,  in  intraligamentous  pregnancy,  practically 
the  whole  of  the  chorion  is  placentous,  and  its  removal  is  accompanied  by  very 
great  bleeding  ;  if,  on  the  other  hand,  the  surgeon  contents  himself  with  removing 
the  foetus  only,  and  trusts  to  the  placenta  to  separate  by  necrotic  disintegration, 
the  possibility  of  septic  infection  further  complicating  the  process  is  considerable . 
When,  however,  the  gestation  sac  is  intraperitoneal,  the  removal  of  the  placenta 
is  often  more  easily  accomplished,  and  especially  so  when  it  is  chiefly  vascu- 
larized by  omental  vessels  through  the  medium  of  adhesions. 

Finally,  it  is  to  be  remembered  that  it  is  generally  impossible  to  find  peri- 
toneum with  which  to  cover  the  site  of  implantation,  and  that  the  adherence 
of  intestine  or  the  formation  of  peritoneal  bands  is  not  uncommon  ;  in  the 
former  case  an  intestinal  obstruction  may  occur,  and  has  been  recorded  as  the 
cause  of  death  in  several  cases. 

3.  The  Condition  of  the  Patient  when  she  comes  under  Treatment. — Opinion 
is  mainly  divided  upon  the  question  of  immediate  interference  or  waiting  until 
the  shock  of  haemorrhage  has  passed  off.  The  preponderance  of  weight  now 
inclines  to  the  view  that  immediate  operation  as  soon  as  the  condition  is 
diagnosed  is  attended  by  the  better  results.  Efficient  treatment  of  the  shock 
and  collapse  from  haemorrhage  will  perhaps  again  start  bleeding,  while  the 
presence  of  the  extravasated  blood  in  the  peritoneal  cavity  is  to  be  regarded 
as  a  constant  source  of  irritation.  Further,  the  operation  is  itself  so  quickly 
performed  in  most  cases,  that  the  additional  shock  may  be  disregarded. 

Reference. — ^Findley,  Diseases  of  Women,  1914,  172.  Bryden  Glendining. 

ECZEMA  AND  ECZEMATOUS  ERUPTIONS.— It  is  impossible  to  lay  down 
brief  rules  for  prognosis  in  eczema,  for  under  that  name  several  conditions  of 
widely  diverse  origin  are  included.  The  points  which  influence  the  prognosis, 
and  the  varieties,  are  as  follows  : — 

I.  Eczema  due  to  External  Irritants. — Many  conditions  known  as  eczema 
are  the  result  of  the  irritation  of  substances  used  in  professions  and  trades.  The 
possible  irritants  are  so  numerous  that  it  would  be  out  of  place  to  enumerate 
them  here.  Certain  soaps,  soda,  prolonged  immersion  in  water,  chemicals  used 
in  manufactures  or  medicinally  applied,  may  all  cause  this  type  of  eruption. 
Exposure  to  strong  sunlight  is  sufficient  to  cause  a  dermatitis  in  some  subjects. 
Certain  plants  act  similarly.  As  a  rule,  on  the  removal  of  the  patient  from  the 
source  of  irritation,  this  form  of  dermatitis  yields  rapidly  to  simple  soothing 
applications.     Recurrence  is  almost  certain  if  the  exposure  to  the  irritant  is 

II 


i62  INDEX     OF     PROGNOSIS 

repeated,  and  in  many  instances  the  skin  becomes  more  and  more  easily  affected 
as  the  attacks  recur.     In  other  instances  a  species  of  immunity  may  be  acquired. 

2.  Parasitic  'Eczema.' — Under  the  name  'eczema'  are  included  certain 
forms  of  eruption  produced  by  ringworm  fungi.  These  occur  especially  in  the 
groin  and  on  the  extremities.  They  yield  to  antiparasitic  remedies,  and  are 
discussed  with  the  ringworms.  The  most  rebellious  cases  are  those  in  which 
the  eruption  occurs  between  the  toes  and  on  the  adjacent  part  of  the  sole. 

3.  'Seborrhoeic  Eczema.' — This  variety  is  associated  with  dandriff  of  the 
scalp  and  a  greasy  condition  of  the  skin,  and  chiefly  affects  the  middle  line  of  the 
trunk,  the  face,  and  the  flexures.  It  usually  clears  up  rapidly  under  treatment 
by  sulphur,  resorcin,  and  salicylic  acid,  provided  the  condition  of  the  scalp  can 
be  controlled. 

4.  Eczema  of  Infants. — This  commonly  involves  the  face.  It  usually  begins 
in  nurslings,  and  is  often  very  intractable.  An  essential  feature  in  successful 
treatment  is  the  avoidance  of  scratching,  which  causes  secondary  pus-coccal 
infection.  In  most  cases  the  dietary  requires  attention.  The  course  is  tedious, 
but  the  prognosis  is  good  on  the  whole  ;  relapses,  however,  are  common,  especi- 
ally during  the  period  of  dentition.  In  a  small  proportion  of  cases  seen  in 
hospital  practice  the  affection  is  persistent,  or  may  for  years  merely  show 
temporary  remissions. 

5.  Eczema  dependent  upon  Antecedent  Conditions  of  the  Skin. — The  xero- 
dermatous  and  ichthyotic  skin  is  very  prone  to  eczema,  which  tends  to  recur 
every  cold  season.  The  eczema  can  usually  be  prevented  by  treating  the 
congenital  condition  by  regular  bathing,  and  by  the  inunction  of  glycerin  and 
water,  or  some  oily  preparation,  daily  ;  this  should  be  made  part  of  the  daily 
toilette. 

Varicose  veins  are  a  common  cause  of  eczema,  and  the  prognosis  depends  upon 
the  possibility  of  the  patient  keeping  the  parts  at  rest.  If  this  can  be  enforced 
the  eczema  soon  yields  to  treatment.  If  the  varices  can  be  removed  by  operation, 
or  if  the  limb  can  be  properly  supported  by  appropriate  bandages,  the  eczema 
may  be  prevented,  but  relapses  are  exceedingly  common. 

The  senile  skin  is  also  prone  to  eczema,  and  very  troublesome  cases  are  met 
with  in  elderly  subjects.     The  prognosis  in  these  cases  is  usually  unsatisfactory. 

6.  Eczema  of  Doubtful  Origin. — In  many  cases  we  are  at  a  loss  to  determine 
the  cause  of  eczema.  We  may  get  evidence  of  gout,  rheumatism,  diabetes, 
renal  disease  ;  or  there  may  be  some  antecedent  general  illness  ;  or,  again,  we 
may  be  entirely  unable  to  account  for  the  condition.  Here  we  have  also  to  treat 
any  general  affection  present,  and  the  prognosis  will  depend  in  the  naain  upon 
our  success  in  determining  and  dealing  with  the  underlying  cause.  Local 
applications  may  frequently  clear  up  an  attack,  and  by  dietetic  measures, 
hydrotherapy,  etc.,  we  may  reheve  the  affection  of  the  skin ;  but  relapses  are 
common  unless  the  primary  condition  can  be  removed.  /.  h.  Sequeira. 

EMPYEMA. — We  have  a  fair  amount  of  reliable  material,  gathered  from  a 
v/ide  area,  from  which  to  judge  of  the  prognosis  of  empyema,  and  the  results  of 
treatment  show  a  remarkable  constancy. 

Prognosis  apart  from  Operation. — Apart  from  treatment  by  evacuation  of 
the  pus,  death  usually  results  from  cachexia,  after  a  long  illness.  A  sudden 
fatality  is  not  uncommon.  Spontaneous  cure,  though  unusual,  is  not  impossible. 
The  patient  usually  goes  on  for  many  weeks  with  fever,  wasting,  and  signs  in  the 
chest  ;  at  length  the  pus  bursts,  either  through  the  chest- wall — commonly  just 
•outside  the  apex-beat  of  the  heart, — or  it  may  be  coughed  up.  This  involves 
some  risk  of  sudden  death  ;    but  if  the  immediate  danger  is  survived,  patients 


EMPYEMA 


163 


sometimes  get  well.  Pneumothorax  may  result.  Bursting  through  the  chest- 
wall  seldom  results  in  cure  ;  a  very  persistent  sinus  generally  remains.  In  both 
methods  of  natural  cure,  the  lung  is  likely  to  have  been  long  pressed  upon,  and 
so  fail  to  expand  properly,  causing  cirrhosis  with  cavities  and  chronic  invalidism. 
Prognosis  after  Drainage  Operations. — In  older  children  and  adults,  the 
mortality  after  drainage  operations  seems,  in  hospital  patients,  to  be  very 
constant  at  about  i  in  5,  as  the  following  table  shows : — 

Mortality  after  Drainage  Operations. 


Reporter 


Lloyd 

Lord 

Schede         .        .        .        .        . 

Lenharz       

Armitstadt  Children's  Hospital- 
St.  Bartholomew's  Hospital 


In  the  great  majority  of  cases  the  operation  involves  removal  of  a  piece  of  rib. 
Simple  puncture,  or  insertion  of  a  tube  without  rib  resection,  is  very  likely  to  be 
followed  by  re-accumulation  of  pus. 

The  mortality  is  influenced  by  (i)  The  age  of  the  patient  ;  (2)  The  bacteriology 
of  the  infection  ;   and  (3)  Whether  the  empyema  is  unilateral  or  bilateral. 

1.  Age. — In  infants  under  two,  there  are  many  deaths.  Natan  reports  145 
cases,  mostly  treated  by  a  drainage  operation,  uith  a  death-rate  of  64  per  cent. 
Zybell  considers  that  simple  puncture,  repeated  when  necessary,  gives  better 
results.  His  figures  are:  of  13  babies  treated  by  puncture,  7  died;  of  7  babies 
treated  by  drainage  operation,  6  died. 

2.  Bacteriology.— With,  reference  to  bacteriology,  the  tubercle  bacillus,  or  an 
apparently  sterile  pus  due  to  tuberculosis,  makes  the  worst  prognosis  ;  mixed 
infections  are  unfavourable  ;  the  pneumococcus  is  favourable  ;  and,  according 
to  Lord,  streptococcal  cases  do  well.  It  is  by  no  means  certain,  however,  that 
Lord's  opinion  as  to  the  benignity  of  the  streptococcus  will  prove  to  be 
universally  correct. 

Prognosis  according  to  Bacteriology. 


Infection 

Eeporter 

Cases 

Cured 

No  better 

Died 

(    Kiister 

31 

9 

6 

16 

Tubercle 

'    Schede 

45 

10 

— 

35 

I    Lord 

9 

1* 

• — 

8 

Mixed  infections     - 

Lord 

27 

— 

— 

5 

Pneumococcus 

Lord 

35 

— 

— 

4 

Streptococcus 

Lord 

17 

— 

— 

1 

— 

— 

*  Recovered  with  a  sinus. 

3.  Double  Empyema  is  a  grave  condition,  but  in  pneumococcal  cases  probably 
about  half  recover. 

The  two  most  favourable  varieties  of  empyema  are,  the  kind  that  arises  with- 
out obvious  cause  in  non-tuberculous  subjects,  and  the  post-pneumonic  form. 
According  to  Lord,  of  288  post-pneumonic  cases,  13  per  cent  died,  the  period  of 
illness  averaging  eighty-three  days  ;  of  loi  idiopathic  cases,  8  per  cent  died, 
the  illness  lasting,  on  an  average,  sixty-six  days. 


i64  INDEX     OF     PROGNOSIS 

Grave  types  are  those  associated  with  pyaemia,  subphrenic  abscess,  phthisis, 
or  abscess  of  the  lung. 

The  operation  itself  is  not  altogether  devoid  of  danger.  Chloroform  deaths 
are  not  very  infrequent  ;  and  there  are  about  a  dozen  cases  on  record  in  which 
convulsions  followed  close  upon  the  evacuation  of  the  pus. 

Eventual  Results.^Much  depends  upon  early  diagnosis  and  operation. 
If  the  lung  has  been  compressed  for  weeks,  it  will  probably  fail  to  expand,  and  a 
persistent  sinus  will  result,  especially  in  tuberculous  patients. 

A  sinus,  however,  is  by  no  means  a  death-warrant.  Godlee  writes  of  two  of  his 
operation  cases  who,  wearing  a  tube,  hved  in  moderately  good  health  for  many 
years,  up  to  seventeen  in  one  instance.  Estlander's  operation  has  a  considerable 
mortality,  perhaps  about  lo  per  cent ;  but  this  varies  much  with  the  number 
of  ribs  that  have  to  be  resected  and  the  condition  of  the  patient's  general  health. 

Lord  followed  13  cases  of  primary  (idiopathic)  empyema  for  a  number  of  years  ; 
9  were  well  four  years  after,  2  died  of  lung  troubles,  and  2  of  intercurrent  disease. 
Of  26  post-pneumonic  cases  investigated  five  years  later,  15  were  well,  i  had 
phthisis,  2  had  had  hemoptysis,  in  i  there  was  a  persistent  sinus,  and  7  were 
dead,  (4  of  lung  affections  and  3  of  intercurrent  diseases). 

References. — Lord,  "  Empyema,"  Osier  and  McCrae's  System  of  Medicine  ; 
Werner,  Deut.  Zeitschr.  f.  Chirurg  1913,  Sept.,  419  ;  Gee  and  Horder,  AUbutt's  System 
of  Medicine,  1909  ed.,  v,  56  ;  Zybell,  Monatschr.  f.  Kinderh.  1912,  xi. 

A.  Rendle  Short 

ENDOCARDITIS.— (See  Rheumatic  Peri-,  Myo-,  and  Endocarditis.) 

ENDOCARDITIS,  ULCERATIVE.— It  may  seem  almost  a  waste  of  time  to 
discuss  the  prognosis  of  so  hopeless  a  disease  ;  but  recent  work  has  shown  that 
the  outlook  is  not  quite  uniformly  desperate. 

The  expectation  of  life,  dating  from  the  onset  of  symptoms,  varies  from  a  few 
days  to  two  or  even  three  years  in  the  cases  that  end  fatally,  while  complete 
recovery  appears  to  occur  in  a  small  percentage.  It  is  difficult  to  say  exactly 
what  that  percentage  is — probably  less  than  five  per  cent  achieve  a  real  cure. 
It  may  even  be  objected  that  this  is  an  unduly  optimistic  figure,  but  allowance 
is  made  in  it  for  the  fact  that  a  more  general  practice  of  making  cultures  from 
the  patient's  blood  is  leading  to  the  recognition  of  a  number  of  comparatively 
benign  cases — cases  which  might  easily  be  mis-labelled  chronic  valvular  disease, 
were  it  not  for  the  application  of  laboratory  methods.  Death  may  be  due  to  a 
variety  of  causes,  the  most  important  being  cardiac  failure,  embohsm  of  brain, 
lung,  or  heart,  uraemia,  and  general  toxaemia. 

The  cases  in  which  recovery  may  ensue  belong  almost  exclusively  to  one 
category.  The  discrimination  between  this  and  other  tj^pes  rests  on  clinical  and 
bacteriological  grounds.  The  symptoms  that  characterize  this  group  of  cases 
are  such  as  suggest  that  the  blood  infection  and  its  results  are  of  a  comparatively 
low  virulence.  Fever  is  moderate,  and  there  may  be  afebrile  intervals  ;  the 
patient  wastes  and  loses  colour,  but  often  so  gradually  that  it  is  difficult  to 
persuade  him  into  a  prudent  way  of  living  ;  there  is  usually  a  history  of  rheumatic 
infection,  with  well-marked  signs  of  valvular  disease  ;  painful,  tender,  erythema- 
tous plaques  are  common,  especially  on  the  fingers  ;  and  the  urine  often  contains 
evidences  of  active  nephritis.  When  blood-cultures  are  made,  the  streptococcus 
which  is  described  in  Germany  as  5.  viridans,  and  classified  by  the  St. 
Bartholomew's  Hospital  workers  with  the  common  streptococci  of  the  ahmentary 
tract,  is  recovered.  Sometimes  the  influenza  bacillus  is  recovered  from  cases 
of  a  similar  clinical  type.  The  picture  is  that  of  chronic  valvular  disease,  with 
evidences  of  a  comparatively  mild  bacterisemia. 


ENTERITIS,     TUBERCULOUS  165 

At  the  other  end  of  the  scale  are  ranged  those  cases  in  which  there  is  high  fever 
with  a  wide  daily  swing,  and  often  with  rigors  ;  the  evidences  of  cerebral 
poisoning — delirium  and  coma — dominate  the  clinical  picture,  and  the  signs  of 
heart  disease  are  unobtrusive — so  much  so  that  they  may  be  overlooked 
altogether.  From  cases  of  this  kind  various  organisms  are  recovered  ;  Staphylo- 
coccus aureus,  Streptococcus  pyogenes,  pneumococcus,  and  gonococcus.  The  course 
is  rapid,  and  invariably  fatal.  Between  the  two  extremes,  every  grade  of 
intensity  may  be  encountered. 

If  generalizations  are  permissible,  it  may  be  said  that  the  discovery  of  the 
Staphylococcus  aureus  or  of  the  Streptococcus  pyogenes  is  a  sure  forewarning  of 
a  fatal  issue  after  a  short  illness  ;  that  infection  with  the  pneumococcus  or 
gonococcus  is  practically  always  fatal  within  a  period  of  three  months  ;  but  that 
in  those  cases  that  are  associated  with  Streptococcus  viridans,  B.  influenzcB,  or 
Staphylococcus  albus,  the  possibility  of  recovery  may  be  entertained. 

From  the  clinical  standpoint,  a  serviceable  general  rule  is  that  the  more  the 
case  is  like  chronic  valvular  disease,  the  less  hopeless  is  the  outlook  ;  but  that 
where  the  case  is  one  of  septicaemia,  with  little  or  no  sign  of  cardiac  disease,  there 
is  no  hope  of  recovery.  An  equally  unfavourable  prognosis  is  to  be  given  in 
those  cases,  seldom  diagnosed  during  life  it  is  true,  where  the  cardiac  infection 
is  predisposed  to  by,  and  terminates,  some  chronic  cachectic  malady  such  as 
consumption,  cancer,  Bright's  disease,  or  diabetes.  The  hopelessness  of  such 
conditions  as  these  is  too  obvious  to  call  for  further  comment.  On  the  other 
hand,  at  least  one  case  of  recovery  is  on  record  in  which  the  infective  process  had 
apparently  attacked  a  congenitally  malformed  heart. 

Even  in  the  comparatively  benign  cases,  the  course  is  usually  run  in  six 
months  ;  and  the  chance  of  complete  recovery  is  still  so  lamentably  slender  that 
it  is  not  fair  to  hold  it  out  as  anything  but  a  forlorn  hope. 

Sudden  death  sometimes  brings  this  disease  to  a  close.  Of  Horder's  150  cases, 
19  ended  in  this  way.  Embolism  or  haemorrhage  into  the  brain,  or  embolism 
of  the  cardiac  wall,  may  be  responsible.  Tearing  of  a  diseased  cusp,  indicated 
by  sudden  change  in  the  murmurs,  with  aggravation  of  the  signs  of  cardiac 
embarrassment,  may  accelerate  death  greatly. 

Influence  of  Treatment  on  Prognosis. — Of  this  there  is  unfortunately  little 
to  be  said.  A  very  few  cases  are  on  record  in  which  the  application  of  specific 
remedies  (autogenous  vaccines  and  sera)  has  appeared  to  save  life,  so  that  it  is 
perhaps  fair  to  claim  that  cases  in  which  treatment  can  be  carried  out  along 
these  lines  stand  a  less  negligible  chance  of  cure  than  those  in  which  it  is  not 
feasible.  Carey  F.  Coombs. 

ENTERIC  FEVER.— (5ee  Typhoid  Fever.) 

ENTERITIS,  TUBERCULOUS. — Owing  to  the  formation  of  adhesions,  general 
septic  peritonitis  is  less  likely  to  occur  in  tuberculous  than  in  other  forms 
of  ulceration  of  the  small  intestine,  though  this  disaster  is  by  no  means 
unknown.  Moreover,  a  general  peritonitis  may  occur  by  organisms,  e.g.,  B. 
coli,  escaping  into  the  general  peritoneal  cavity  through  a  very  much  thinned 
intestinal  wall,  without  actual  perforation.  More  commonly,  fistulous  communi- 
cations are  established  into  other  parts  of  the  intestine,  or  into  localized 
abscesses.  Strictures  may  arise  from  fibrotic  healing  of  the  ulcers,  but  it  is 
rare  for  these  to  give  rise  to  subsequent  intestinal  obstruction.  Fatal  haemor- 
rhage may  occur.  The  ultimate  prognosis  depends,  in  the  vast  majority  of 
cases,  on  the  presence  of  tuberculosis  elsewhere  in  the  body.  This  is  generally 
in  the  lungs,  peritoneum,  or  mesenteric  glands.  /.  R.  Charles. 


1 66 


INDEX     OF     PROGNOSIS 


EPIDIDYMITIS,  TUBERCULOUS. — It  is  difficult  and  unsatisfactory,  in  one 
respect,  to  discuss  the  prognosis  of  an  affection  which  is  probably,  in  the  great 
maj  ority  of  cases,  only  the  most  evident  manifestation  of  an  extensive  involvement 
of  the  genito-urinary  organs.  It  is  obvious  that  the  eventual  outlook  must 
usually  depend  more  upon  the  state  of  the  bladder,  prostate,  and  kidneys,  than 
upon  the  treatment  of  the  testis.  Tuberculosis  of  the  urinary  organs  is  discussed 
elsewhere.     (See  Kidney,  Tuberculous,  and  Bladder,  Tuberculous.) 

We  shall  here  include  tuberculous  orchitis  with  epididymitis. 

It  has  been  much  debated  whether  an  epididymitis  is  the  primary  manifesta- 
tion of  tuberculosis  in  the  genito-urinary  organs ;  but  favour  of  late  has  rather 
been  accorded  to  the  opinion  that,  in  most  patients,  the  kidney,  though  it 
may  show  no  signs  itself,  passes  out  living  tubercle  bacilli  which  invade  the 
prostate,  leading  to  a  secondary  infection  of  the  vas,  and  then  of  the  epididymis 
and  testis.  It  is  true  that  the  finger,  examining  from  the  rectum,  is  frequently 
unable  to  feel  anything  in  the  prostate,  but  at  autopsy  this  gland  is  always 
diseased  ;  it  has  lately  been  declared,  contrary  to  the  general  teaching,  that 
infection  of  the  epididymis  begins  in  the  globus  minor  (that  is,  nearer  the  prostate) , 
not  in  the  globus  major.  All  this,  of  course,  has  an  important  bearing  on 
prognosis. 

We  have  very  little  evidence  as  to  the  fate  of  a  tuberculous  testis  left  to  itself. 
No  doubt  the  immense  majority  of  such  cases  perforate  the  skin  and  lead  to 
chronic  suppuration  ;  extension  of  the  disease  will  also  probably  take  place. 
A  few  non-operated  cases  go  on  without  much  change,  or  even  with  some  improve- 
ment, under  treatment  with  tuberculin ;  but  there  is  little  prospect  of  a  cure,  and 
great  risk  of  generalization. 

Results  of  Operative  Removal. — We  have  to  discuss  the  end-results  of  three 
methods  of  treatment  by  operation :  removal  of  the  epididymis,  unilateral 
castration,  and  bilateral  castration. 

The  immediate  mortality  after  operation  is  very  small  indeed.  Some  patients, 
however,  fall  victims  to  acute  general  tuberculosis  within  a  few  months.  The 
proportion  is  given  as  5-5  per  cent  by  Barney.  Much  depends  on  the  surgeon's 
judgement  in  accepting  or  rejecting  the  worst  type  of  cases. 

End-results    of    Removal    of    Tuberculous    Testis    or    Epididymis. 


Cases 
followed 

Cured 

Tuberculous  elsewhere 

Died  o( 
tubercu- 
losis 

Lungs 

Bladder 

other 

testis 

Various 

Barney* 

Von  Bruns  -            - 

Simon 

Horwitz 

Bristol  Royal  Infirmary    - 

71 

92 
30 
16 

per  cent 

62 

4f) 

57-6 

60 

62 

per  cent 

3 
6 

per  cent 

12 

per  cent 
26 

7 
12 

per  cent 

32 

6-6 

I 

per  cent 

5-5 

35  "5 
23-3 

12 

64  per  cent  of  these  cases  followed  less  than  a  year. 


For  determining  the  end-results,  we  have  several  valuable  publications  to 
guide  us  ;  but  the  subject  is  complicated,  and  some  of  the  statistics  are  scanty  in 
detail  or  compiled  too  soon  after  the  operation.  Thus,  Barney  published  in  1912 
some  American  hospital  figures  ;  but  two-thirds  of  his  71  cases  were  followed  less 
than  a  year,  so  that  his  rate  of  cure,  62  per  cent,  is  high,  and  the  after-fatalities, 
5-5  per  cent,  are  much  too  few.  In  many  points,  however,  his  results  are  interest- 
ing and  valuable,  as  we  shall  see. 


EPIDIDYMITIS,     TUBERCULOUS  167 

Von  Bruns  and  Simon  publish  statistics  of  patients  traced  from  three  years 
upwards.  The  first  finds  46  per  cent  cured  by  unilateral  castration,  and  56  per 
cent  by  bilateral  castration.  Simon  finds  57-6  per  cent  cured,  and  35'8  per  cent 
dying,  out  of  92  cases.  Horwitz  reports  a  small  series,  mostly  followed  for  more 
than  a  year  :  60  per  cent  were  cured  and  23-3  per  cent  died.  At  the  Bristol 
Royal  Infirmary,  of  16  cases  all  followed  over  eighteen  months,  10  were  cured,  i 
developed  phthisis,  2  suffered  from  cystitis  (present  before  operation),  2  developed 
tuberculosis  of  the  other  side,  and  2  (including  one  of  these  last)  died  of  pulmonary 
tuberculosis. 

We  may  conclude,  therefore,  that  when  followed  for  several  years  afterwards, 
perhaps  rather  more  than  half  the  cases  are  quite  cured,  and  about  20  per  cent 
die  of  tuberculosis  elsewhere.  The  remainder  continue  to  suffer  from  various 
tuberculous  affections,  such  as  cystitis,  prostatic  abscess,  phthisis,  etc.,  which 
were  no  doubt  already  present  at  the  time  of  operation.  In  Barney's  series, 
nearly  half  the  patients  had  some  evidence  of  tuberculosis  elsewhere  than  in  the 
testis  when  they  were  first  seen  ;  in  63  per  cent,  the  prostate  or  vesicute  were 
affected. 

There  is  some  evidence  that  these  coincident  manifestations  of  tubercle  may 
improve  after  removal  of  the  testis  or  epididymis.  Thus,  of  the  63  per  cent  of 
cases  with  palpable  nodules  in  the  prostate  or  vesiculse  before  operation,  Barney 
found  that  18  per  cent  disappeared,  leaving  45  per  cent  in  statu  quo. 

Recurrence  in  the  other  testis  was  observed  in  2  out  of  16  Bristol  cases,  in 
29  per  cent  of  von  Bruns'  series,  and  in  7  per  cent  of  Horwtz's.  It  ma\'' 
be  quite  late  ;  in  one  of  the  Bristol  cases  it  occurred  six  years  after  the 
first  operation. 

Sexual  power,  according  to  Barney,  was  retained  in  60  per  cent  of  the  cases ; 
but  azoospermia  was  present  in  11  out  of  13.  There  are,  however,  plenty  of 
instances  recorded,  i  in  the  Bristol  series,  in  which  healthy  children  are  born 
afterwards.  The  wife  and  child  do  not  appear  to  be  infected.  Even  bilateral 
castration  has  no  demorahzing  effect  ;  if  performed  before  puberty,  it  arrests 
the  development  of  the  secondary  sexual  characters. 

The  fatal  cases  die  of  general  tuberculosis,  phthisis,  or  uraemia  from  tuberculous 
kidneys. 

Results  as  regards  Treatment. — ^With  reference  to  the  effects  of  treatment,  we 
have  to  consider  unilateral  castration,  bilateral  castration,  epididymectomy,  and 
tuberculin. 

On  paper,  the  results  of  epididymectomy  are  better  than  those  of  unilateral 
castration.  Horv/itz  gives  i  out  of  11  dying  after  the  former,  and  6  out  of  19 
after  the  latter.  Barney  also  claims  greater  success.  This  merely  means,  of 
course,  that  less  extensive  cases  give  better  results  than  those  in  which  the 
testis  is  already  infected,  but  it  affords  justification  for  the  practice  of  leaving 
the  testis  if  it  appears  to  be  uninvolved. 

Double  castration  may  be  necessary,  but  it  by  no  means  makes  a  hopeless 
prognosis  ;  indeed,  both  von  Bruns  and  Simon  claim  better  results  in  these 
cases  than  in  those  in  which  only  a  unilateral  castration  was  performed. 

Tuberculin  appears  to  be  of  very  decided  value  in  the  treatment  of  this  and 
other  tuberculous  affections  of  the  genito-urinary  tract ;  but  its  claims  rest  rather 
on  individual  reports  than  upon  statistics. 

To  recapitulate  :  Rather  more  than  half  the  patients  get  quite  well  ;  about 
20  per  cent  die  of  tuberculosis  elsewhere.  Bilateral  cases  are  no  worse  than 
unilateral  in  the  eventual  results.  For  early  cases,  epidid^miectomy  is  as 
satisfactory  as  castration.  The  operation  often  leads  to  improvement  of  the 
prostatic  nodules,   if  present.     The  prognosis  in  individual  cases  depends  far 


i68  INDEX     OF     PROGNOSIS 

more  upon  the  tuberculosis  of  the  bladder  and  other  organs  than  upon    the 
condition  of  the  external  genitals. 

References. — Barney,  Boston  Med.  and  Surg.  Jour.  1912,  clxvi,  409  ;  Horwitz,  Jour. 
Amer.  Med.  Set.  1902,  xxxviii,  1607 ;  von  Bruns,  Centr.  f.  Chir.  1901,  Report  of 
Congress,  119  ;   Simon,  ihid.,  125.  a.  Rendle  Short. 

EPILEPSY. 

The  Prospects  of  Spontaneous  Cure,  i.e.,  cure  without  medicinal  treatment, 
are  so  small  as  to  be  almost  negligible,  and  therefore  the  occurrence  even  of  a 
single  epileptic  fit  calls  for  a  prolonged  and  assiduous  course  of  treatment.  One 
epileptic  fit  favours  the  occurrence  of  another,  since  the  fit  increases  the  instability 
of  the  cerebral  cortex.  In  female  patients,  puberty  and  the  menopause,  so  far 
from  exercising  a  beneficial  influence  on  the  fits,  as  has  been  popularly  supposed, 
have  quite  a  contrary  effect.  Both  of  these  physiological  crises  are  associated 
with  profound  disturbance  of  metabolic  equilibrium,  during  which  any  irrita- 
bility of  the  cerebral  cortex  is  more  likely  to  be  increased  than  diminished,  and, 
in  fact,  puberty  is  a  specially  common  time  for  epileptic  fits  to  commence.  Some- 
times infantile  epilepsy  ceases  spontaneously  at  the  age  of  four  to  five  years, 
but  this  cannot  be  held  out  as  a  probability  in  any  individual  case.  As  a  rule,  the 
later  in  life  the  disease  appears,  the  greater  are  the  chances  of  spontaneous  arrest. 
Marriage  of  an  epileptic  has  no  material  influence  on  the  disease,  either  beneficial 
or  otherwise.  Pregnancy  sometimes  arrests  the  fits  temporarily,  but  they 
generally  return  after  the  pregnancy  is  over. 

The  Danger  to  Life  in  idiopathic  epilepsy  is  not  great,  despite  the  alarming 
appearances  presented  by  the  epileptic  patient  during  the  actual  fit.  Status 
epilepticus  (where  one  fit  follows  another  in  rapid  succession  without  the  patient 
recovering  consciousness  between  the  individual  fits  of  the  series)  is  relatively  rare, 
but  it  may  be  fatal  from  exhaustion  and  heart  failure.  The  chief  practical  risk 
to  life  is  that  the  epileptic  patient  may  die  accidentally,  during  a  fit — -most 
commonly  by  drowning  through  falling  into  water,  an  inch  or  two  being  enough 
to  prove  fatal,  since  the  fit  prevents  the  patient  from  making  any  effort  to  save 
himself.  Other  epileptics  may  die  from  asphyxia,  by  rolling  over  on  the  face  in 
bed  during  an  attack.  Others,  again,  may  inhale  food  into  the  air-passages,  if  the 
fit  occurs  during  a  meal ;  or  vomited  material  may  be  re-inhaled,  with  the  same 
result.  These,  however,  are  secondary  '  accidents  '  ;  so  also  are  the  frequent 
injuries  to  the  head  and  face  sustained  during  falling,  and  the  occasional  burns 
which  result  from  falling  on  to  a  fire.  All  of  these  '  accidents  '  can  be  obviated 
only  by  close  watching  of  the  patient,  and  never,  under  any  circumstances, 
leaving  him  unobserved. 

Prospects  of  Cure  or  Arrest  by  Treatment. — Epilepsy  is  one  of  the  diseases  in 
which  medicinal  treatment  often  succeeds  in  profoundly  modifying  the  disease, 
either  by  diminishing  or  abolishing  the  attacks,  or  by  altering  the  t^'pe  of  the 
paroxysms  during  the  time  that  treatment  is  persevered  with.  The  prognosis 
in  an})-  individual  case  depends  largely  upon  the  personal  reaction  of  the  patient 
to  the  remedies  prescribed,  and  the  assiduity  with  which  these  remedies  are 
administered.  Even  where  the  fits  do  not  entirely  cease,  treatment  may  some- 
times enable  a  patient  to  live  an  active  and  useful  life  in  place  of  an  existence 
which  is  distressing  to  the  patient  himself  and  to  those  on  whom  he  is  dependent. 
From  a  series  of  cases  observed  by  Govv^ers,  the  following  main  conclusions  were 
drawn  in  regard  to  factors  affecting  the  outlook  : — 

Age. — The  younger  the  patient  at  the  age  of  onset,  the  less  is  the  prospect  of 
cure.  Cases  beginning  between  the  ages  of  ten  and  twenty  have  relatively  the 
worst  prognosis  ;    those  beginning  before  the  age  of  ten  are  somewhat  more 


EPILEPSY  169 

favourable.  The  most  favourable  are  those  which  commence  after  the  age  of 
twenty  (with  the  exception  already  referred  to,  viz.,  that  cases  beginning  in 
women  at  the  menopause  have  an  unfavourable  prognosis). 

Sex. — The  prognosis  is  slightly  better  in  males  than  in  females,  possibly  owing 
to  the  intercurrent  factors  of  menstruation  and  of  the  menopause  in  the  female 
sex. 

Previous  Duration  of  the  Disease. — The  shorter  the  duration,  the  brighter  are 
the  prospects  of  its  yielding  to  treatment.  Cases  which  have  lasted  for  less  than 
a  year  are  the  best  of  all  :  if  the  disease  has  existed  for  five  years  or  less,  the 
chances  are  only  fair  :  if  the  fits  have  been  occurring  for  more  than  five  years, 
complete  arrest  is  almost  unattainable,  and  we  usually  have  to  be  content  with 
a  mere  diminution  in  their  frequency. 

Intervals  between  Attacks. — Severe  attacks,  when  occurring  daily,  are  unlikely 
to  be  arrested.  Attacks  occurring  at  intervals  longer  than  a  month  have  the 
most  hopeful  prospect.  Attacks  occurring  regularly  once  a  month,  in  relation 
to  a  menstrual  period — whether  before,  during,  or  after  each  period, — are  relatively 
more  difficult  to  arrest  than  those  where  the  attacks  occur  at  somewhat  shorter, 
but  irregular,  intervals. 

The  Waking  or  Sleeping  State,  during  which  the  fits  habitually  occur,  is  of 
importance.  If  the  attacks  occur  only  in  the  waking  state  and  not  during  sleep, 
or  only  during  sleep  but  not  when  awake,  the  prospects  are  three  times  as  bright 
as  when  they  occur  both  asleep  and  awake.  The  prognosis  is  rather  better  in 
pure  nocturnal  than  in  pure  diurnal  epilepsy. 

The  Major  or  Minor  Character  of  the  Fits  has  to  be  borne  in  mind.  Major  fits 
are  much  more  easily  influenced  by  treatment  than  minor  fits.  It  is  not  un- 
common for  the  minor  fits  to  persist,  in  spite  of  treatment,  after  the  major  fits 
have  been  completely  arrested.  The  minor  attacks  may  even  become  more 
frequent.  Nevertheless,  it  is  of  supreme  importance  to  persevere  with  treatment, 
since,  if  it  be  suspended,  the  major  fits  are  almost  certain  to  reappear. 

Hereditary  Disposition  to  epilepsy,  contrary  to  expectation,  does  not  appear 
to  render  the  epileptic  patient  less  amenable  to  treatment.  Gowers  has  been 
strongly  impressed  with  the  frequency  with  which  hereditary  cases  responded 
successfully  to  treatment. 

Mental  Change,  whether  dullness  or  irritability,  is  an  unfavourable  sign.  We 
must  bear  in  mind  that  some  cases  of  apparent  mental  dullness  in  epilepsy  may 
be  due  to  excessive  bromide  medication. 

The  Occurrence  of  an  Aura  appears  to  render  the  prognosis  slightly  more  favour- 
able ;  possibly  because,  in  such  cases,  the  patient  may  sometimes  be  trained  by  an 
effort  of  will  to  fight,  during  the  time  of  the  aura,  against  his  threatened  fit.  The 
precise  variety  of  aura  appears  to  have  but  slight  significance  in  this  respect. 

The  Apparent  Exciting  Cause  of  the  first  Fit  is  occasionally  of  importance  with 
regard  to  prognosis.  Thus,  I  remember  one  case  in  a  young  medical  student,  in 
whom  a  first  and  only  epileptic  fit  occurred  during  the  excitement  of  an  election 
free-fight.  The  patient  avoided  exciting  meetings  thereafter,  and  never  had 
another  fit.  I  have  also  seen  a  number  of  cases,  chiefly  in  adolescents,  in  whom 
some  unusual  article  of  diet  (e.g.,  salmon,  ice-cream,  sausage,  etc.)  had  been 
consumed  at  the  meal  immediately  preceding  each  attack,  and  at  no  other  time  ; 
in  others,  each  fit  was  preceded  by  a  definite  attack  of  constipation.  Such 
classes  of  patients  chiefly  consisted  of  cases  in  which  the  fits  occurred  at  long 
intervals  of  months,  and  even  of  several  years.  Attention  to  the  diet  and  careful 
regulation  of  the  bowels  are  of  importance  in  every  epileptic  patient.  Frequently, 
however,  no  constant  exciting  cause  can  be  traced,  and  its  presence  or  absence 
does  not  appear  very  materially  to  influence  the  prospect  of  cure. 


170 


INDEX     OF     PROGNOSIS 


The  ultimate  prognosis  depends  upon  the  patience  and  assiduity  with  which 
the  patient  and  his  friends  can  be  induced  to  carry  out  the  treatment.  Treat- 
ment, dietetic,  hygienic,  and  medicinal,  must  be  persevered  with  for  a  long  time 
after  the  fits  have  ceased.  Two  years  without  a  fit  is  commonly  agreed  to  be  the 
shortest  period  that  should  elapse  before  treatment  is  relaxed.  Even  then,  the 
bromide  should  not  be  withdrawn  suddenly,  but  gradually,  grain  by  grain,  so  as 
not  to  expose  the  brain  to  sudden  stress.  Purves  Stewart. 

EPITHELIOMA  OF  LIP.— (See  Lip,  Cancer  of.) 

EPITHELIOMA  OF  TONGUE.— (See  Tongue,  Cancer  of.) 

EPULIS. —  (See  Jaws,  Tumours  of.) 

ERYSIPELAS. — -A  simple  attack  of  cutaneous  erysipelas,  in  a  healthy  person, 
is  almost  free  from  danger.  The  inflammation  usually  lasts  about  a  week. 
Recurrence  is  not  uncommon  in  those  cases  which  appear  to  be  independent 
of  a  wound. 

Extensive  cases,  or  those  occurring  in  infants,  the  aged,  sufferers  from  Bright's 
disease  or  diabetes,  or  alcoholics,  are  of  much  graver  import.  High  fever  and 
delirium,  and  the  development  of  pyaemic  abscesses,  point  to  a  probable  fatal 
issue. 

The  mortality  in  875  cases  at  St.  Bartholomew's  Hospital,  a  good  many  years 
ago  now,  was  3'5  per  cent,  being  rather  heavier  in  males  than  females.  When 
there  was  definite  cellulitis  as  well  as  erysipelas,  the  mortality  was  much  higher : 
II  per  cent  in  889  cases.  A.  Rendle  Short. 

ERYTHREMIA.— (See  Polycythemia.) 

EXOPHTHALMIC  GOITRE In  this  disease  it  will  be  necessary  to  investi- 
gate the  results  of  various  forms  of  medical  treatment ;  of  surgical  treatment ; 
the  dangers  to  which  the  patients  are  liable  ;  and  finally,  the  factors  that  make 
for  a  good  or  a  bad  prognosis. 


Results  of  Medical 

AND  Surgical  Treatment, 

Total 
Cases 

Died  in 
H'pital 

Cases  followed  THSonoH 

PARTICULARS 

Total 

Much 

No 

Died 

thro' 

Better 

Better 

Better 

since 

per  cent 

percent  percent 

percent 

percent 

per  cent 

/I.  Hale  White  (hospital) 

161 

11 

48 

54 

0 

25 

5 

16 

"^2.       „         ,,      (private) 

55 

0 

54 

64 

0 

17 

6 

13 

0     3.   Rogers  (antithyroid  serum)    - 

480 

0 

240(?) 

30 

20 

0 

34 

16 

Q      4.  Jackson  &Eastman(quin.HBr.) 

56 

0 

56 

76 

0 

13 

11 

0 

g     5.  Williarnson  and  Mackenzie     - 
v6.  Stoney  (;v  rays) 

56 

0 

56 

18 

20 

30 

8 

24 

43 

0 

41 

34 

54 

10 

0 

2* 

^  Ti.   Kocher  (progressive  Graves') 

539 

3 

360t 

45 

0 

41 

8 

6 

<     2.   Kuttner          .... 

64 

17 

37 

34 

36 

17 

14 

0 

"     3.  Mayo  (ligature  of  arteries) 

225 

2 

115 

2 

48 

9 

Sit 

9 

«     4.  Boisson  (sympathectomy) 

27 

11 

15 

13 

40 

20 

7 

20 

,5     5-  Guy's  &  St.  Thomas's  Hosp.  - 
^  U-  Berry 

23 

33 

13 

8 

0 

61 

31 

0 

28 

11 

— 

—    1    — 

— 

— 

— 

•  Died  of  a  subaequent  operation;   not  improved  by  x  rays. 
+  Many  of  these  had  more  than  one  operation. 
4  Mo&t  of  these  had  a  subsequent  thyroidectomy. 


EXOPHTHALMIC    GOITRE  171 

Medical  Treatment. — The  tables  that  have  been  pubhshed,  giving  end-results, 
require  examination  before  they  can  be  generally  accepted.  Some  authors  are 
over-enthusiastic  on  behalf  of  a  special  mode  of  treatment ;  others  are  meagre 
in  details.  Perhaps  Hale  White's^  statistics  command  most  confidence,  full 
particulars  being  given  for  each  case,  based  almost  entirely  on  a  communi- 
cation from  the  patient  herself  or  her  medical  attendant.  The  treatment  was 
very  diverse,  including  digitalis,  belladonna,  arsenic,  thymus,  Moebius'  serum, 
and  other  drugs  ;  most  of  the  private  cases  were  ordered  prolonged  rest  in  bed, 
which  Hale  White  considers  of  the  first  importance.  It  must  be  borne  in  mind 
that  the  mildest  cases  would  not  be  adequately  represented  in  these  figures, 
as  such  would  not  be  so  likely  to  become  hospital  in-patients  or  to  seek  the 
consultant. 

It  will  be  observed  that  about  11  per  cent  of  Hale  White's  hospital  cases  died 
in  the  institution  ;  that  of  those  followed  through,  more  than  half  recovered  more 
or  less  completely,  a  quarter  improved,  a  few  remained  in  statu  quo,  and  about 
16  per  cent  have  since  died.  The  private  cases  did  decidedly  better,  about  64 
per  cent  recovering,  while  only  13  per  cent  died  subsequently.  Most  of  these 
patients  have  been  followed  up  for  several  j^ears.  With  reference  to  those  who 
have  died  since,  the  mortahty  appears  to  be  about  double  that  of  healthy 
females  of  the  same  age. 

Rogers^  presents  figures,  without  full  details,  illustrating  the  results  obtained 
by  the  use  of  his  antithyroid  serum.  No  doubt  rest  and  regimen  must  bear  a 
share  in  the  credit.  The  treatment  does  not  appear  to  improve  upon  the  success 
obtained  by  other  methods.  About  30  per  cent  are  quite  cured,  and  one-half 
altogether  experience  great  improvement.  The  percentage  of  those  not 
improved  is  high. 

Jackson  and  Eastman^  publish  statistics  of  treatment  by  neutral  quinine 
hydrobromide,  in  addition  to  rest  and  general  supervision,  and  the  percentage 
of  cases  cured  or  greatly  benefited  is  high  ;    the  details,  however,  are  meagre. 

Data  collected  from  the  practice  of  Williamson  and  Mackenzie*  are  presented 
by  the  last  named,  a  variety  of  methods  of  treatment  having  been  followed. 
The  results  are  not  so  good  as  Hale  White's,  only  18  per  cent  being  cured  and 
20  per  cent  greatly  improved,  whereas  the  latter  reports  about  60  per  cent 
recovered  more  or  less  completely 

There  is  no  convincing  evidence  favouring  any  special  drug  treatment,  and 
it  would  appear  that  of  cases  sufficiently  ill  to  require  hospital  treatment  or  a 
specialist's  opinion,  about  half  get  well  or  almost  well,  20  per  cent  improve, 
about  10  per  cent  do  not  improve,  and  the  mortality  rate  is  about  twice 
the  normal. 

The  end-results  of  ;ir-ray  treatment^  compare  favourably  with  other  methods, 
but  the  figures  are  rather  small,  and  only  about  half  of  the  cases  described  as 
'  cured  '  or  '  almost  cured  '  had  been  followed  for  a  year  or  longer  ;  it  cannot 
therefore  be  regarded  as  proved  that  the  x  rays  are  a  great  advance  on  other 
treatment.     In  some  reports  they  have  not  given  particularly  good  results. 

Surgical  Treatment. — This  has  made  far  more  headway  on  the  Continent  and 
in  America  than  in  England,  where  it  has  been  reserved  for  the  worst,  not  to  say 
totally  unsuitable,  type  of  cases,  and  is  thus  put  to  a  severe  test. 

Three  operations  are  in  current  use  :  complete  or  partial  excision  of  the 
sympathetic  ganglia  of  the  neck,  or  section  of  the  connecting  nerves  ;  ligature 
of  the  superior  thyroid  arteries  ;    and  removal  of  one  half  of  the  thyroid  gland. 

Data  concerning  cases  of  sympathectomy,  followed  up  afterwards,  and  dealing 
only  with  instances  of  undoubted  Graves's  disease,  are  not  easy  to  find.  Boisson*^ 
has  published   a  record  of  15  answering  to  this  description,  of  whom  2   were 


172  INDEX    OF     PROGNOSIS 

cured  and  6  greatly  improved,  but  it  is  not  clear  that  the  benefit  followed  very 
closely  on  the  operation.  Out  of  27  operated  on,  3  died  soon  afterwards. 
The  rationale  of  the  treatment  is  open  to  doubt,  and  it  is  said  that  blindness 
may  follow. 

Although  the  Mayos  proceed  to  remove  half  the  thyroid  at  a  second  operation 
if  the  first  is  not  successful,  they  publish  figures"  giving  the  end-results  of 
cases  in  which  the  treatment  adopted  has  been  ligature  of  the  superior  thyroid 
arteries.  The  details  are  scanty.  The  operation  mortality  was  only  2  per  cent. 
A  few  cases  were  cured  ;  about  half  were  greatly  improved,  but  about  a  third 
were  either  not  improved  or  had  to  submit  to  the  second  operation  of  hemi- 
thyroidectomy. 

In  the  majority  of  Kocher's  cases  half  the  gland  is  removed.  ^  He  divides  his 
patients  into  two  groups  ;  in  the  first  there  are  symptoms  of  h>'perthyroidism 
which  are  neither  permanent  nor  progressive,  associated  with  a  parenchymatous 
or  adenomatous  goitre.  Except  that  two  patients  died  of  pneumonia  (out  of 
130),  the  results  of  operation  were  uniformly  good.  In  the  second  group  of  539 
cases  there  were  progressive  S5anptoms  of  Graves's  disease  ;  here  the  mortality 
was  3  per  cent.  He  lays  great  stress  on  the  use  of  a  local  anaesthetic.  Although 
the  majority  of  the  patients  had  been  suffering  long  and  severely,  nearly  half 
were  completely  cured  even  when  watched  for  many  years,  but  they  often 
required  more  than  one  operation,  the  first  removal  having  proved  too  limited. 
The  cases  classed  as  '  better  '  were  able  to  earn  their  living  ;  these  amounted 
to  41  per  cent. 

Kuttner's  *  figures  are  about  equally  favourable,  although  he  admits  a  much 
higher  mortality  (eleven  out  of  sixty-four). 

In  two  London  hospitals,  Guy's  and  St.  Thomas's,  quoted  by  Hale  White  and 
Mackenzie,  the  results  are  less  satisfactory,  but  it  is  probable  that  they 
represent  a  much  severer  type  of  case.  One -third  of  the  patients  died,  and 
although  the  majority  of  those  who  survived  were  improved,  several  were  not 
benefited,  and  only  one  was  absolutely  cured. 

Berry,  1"  however,  has  published  a  far  more  successful  series  of  cases.  He  oper- 
ated on  28  patients,  including  one  who  died  on  the  table  before  the  first  incision 
was  made.  Two  others  died  within  a  few  days  ;  25  recovered  well,  and  of  these 
all  were  benefited,  some  to  a  most  remarkable  degree,  but  others  relapsed. 
Every  one  of  these  patients  had  marked  Graves's  disease,  with  exophthalmos. 

The  immediate  dangers  of  operation  are  considerable.  The  patients  take 
a  general  anaesthetic  very  badly,  and  a  good  many  have  died  on  the  table  ;  on 
the  other  hand,  the  pitiable  nervousness  makes  the  strain  of  operation  under 
local  anaesthesia  great,  and  Kocher  admits  that  a  considerable  number  are  very 
much  upset,  with  rapid  pulse,  fever,  and  other  alarming  symptoms.  Again, 
patients  with  exophthalmic  goitre  have  frequently  an  enlarged  thymus,  which 
may  precipitate  sudden  death.  Interference  with  the  gland  may  lead  to  a  pro- 
fuse outpouring  of  thyroid  secretion  into  the  veins,  with  symptoms  of  acute 
hyperthyroidism,  including  very  rapid  irregular  pulse,  fever,  delirium,  and 
increased  exophthalmos  :  this  maj''  end  in  death  within  a  day  or  two.  Crile's 
anoci-association  methods,  and  the  administration  of  large  quantities  of  saline 
per  rectum,  help  to  avert  these  dangers.  Occasionally  tetany  has  followed, 
from  injury  or  removal  of  the  parathyroid  glands. 

A  comparison  of  the  end-results  of  medical  and  surgical  treatment,  even  if  we 
neglect  the  London  hospitals'  records  as  abnormally  bad  and  Kocher's  first  group 
as  abnormally  favourable,  do  not  show  any  advantage  gained  by  operation. 
One  benefit,  however,  is  not  brought  out  by  figures  :  the  medical  treatment  is 
long  and  tedious,  whilst  the  operation,  if  successful,  leads  to  a  much  quicker  cure. 


EXOPHTHALMIC     GOITRE  173 

To  obtain  best  results  from  surgery,  cases  must  be  taken  at  the  favourable  time. 
As  the  Mayos  and  Berry  have  pointed  out,  the  toxaemia  advances  to  a  certain 
degree,  attains  a  maximum  usually  towards  the  end  of  the  first  year,  and  then 
subsides,  and  the  proper  time  for  interference  is  either  early  or  late,  but  not  at 
the  height  of  the  toxaemia.  It  is  dangerous  to  operate  on  patients  with  a  mark- 
edly dilated  and  irregular  heart,  great  muscular  prostration,  great  excitability, 
persistent  albuminuria  or  glycosuria,  or  lymphocytosis  with  leucopenia.  Great 
emaciation,  however,  is  not  a  contra-indication  per  se.  When  there  is  doubt  as 
to  the  patient's  ability  to  stand  an  operation,  it  will  be  wise  to  content  oneself 
with  ligature  of  the  superior  thyroid  arteries,  proceeding  to  hemithyroidectomy 
at  a  later  date  if  necessary. 

With  these  precautions,  the  present-day  operative  mortality  is  not  above 
10  per  cent,  and  the  Mayos  have  now  had  a  consecutive  series  of  278  cases  with- 
out a  death. 

Sequelae. — Like  other  chronic  invalids,  patients  are  liable  to  various  chest 
complaints,  and  also  to  profuse  or  uncontrollable  diarrhcea.  In  many  of  Hale 
White's  hospital  cases,  vomiting  or  diarrhoea  was  responsible  for  the  fatal  issue  ; 
in  his  private  practice,  where  the  patient  is  more  likely  to  be  put  to  bed  and  to 
be  suitably  fed  from  the  first,  this  complication  was  much  less  in  evidence. 

Nervous  Symptoms,  such  as  delirium  or  coma,  are  not  uncommon  at  the 
termination,  and  usually  point  to  a  rapid  dissolution.  Mania  or  melancholia 
may  also  occur. 

Cardiac  dilatation  is  fairly  frequent,  and  acute  attacks  may  lead  to  sudden 
death.     A  mitral  murmur  may  appear. 

Rarely,  the  exophthalmos  so  increases  that  ulceration  of  the  cornea,  or  even 
blindness,  may  result,  or  the  eye  may  be  dislocated  forwards  on  to  the  face. 

Glycosuria  is  not  uncommon,  and  several  of  Hale  White's  cases  died  of  diabetes. 
In  other  patients,  intervals  of  hypothyroidisna  (myxoedema)  alternate  with 
periods  of  hyperthyroidism. 

Relapse  may  occur  even  after  many  months  or  years  of  apparently  perfect 
health.  In  one  case  known  to  the  writer  a  relapse  was  induced  after  more  than 
twelve  years  of  entire  freedom  from  symptoms  ;  the  first  attack  was  brought 
on  by  a  head  injury  and  the  second  by  iodoform  poisoning.  In  the  great  majority 
of  instances,  however,  relapse  does  not  occur  if  once  complete  freedom  from 
symptoms  is  obtained  for  any  length  of  time.  Patients  stand  confinements  very 
well,  even  if  the  disease  is  still  present  in  mild  degree.  Many  so-called  relapses 
are  really  exacerbations  of  symptoms  which  had  only  partially  subsided. 

Prognosis  in  Individual  Cases. — In  Hale  White's  tables,  the  cases  are  grouped 
according  to  the  severity  of  the  symptoms  and  the  eventual  result.  We  combine 
the  hospital  and  the  private  patients  here. 


Mild  or  Average 

Severe 

Very  Severe 

Cases  that  have  done  well 
Cases  moderately  well,  or  better 
Cases  that  did  not  do  well 

Total     - 

36 

16 
4 

5f) 

16 
4 

1 

21 

9 
1 
0 

10 

Many  of  Kocher's  successful  cases  were  very  ill  ;  in  one  of  these  the  eye- 
ball had  prolapsed  and  had  to  be  replaced,  yet  now  the  patient  is  quite  weU, 
with  no  exophthalmos.  Severity  of  the  ordinary  symptoms,  then,  does  not 
make  a  bad  prognosis.  Cases  that  come  on  acutely  usually  get  well  rapidly,  even 
if  they  become  very  ill  for  a  time. 


174  INDEX     OF     PROGNOSIS 

There  are  certain  danger-signals.  Diarrhcea  and  vomiting  that  do  not 
yield  soon  to  rest  in  bed  and  suitable  feeding  are  of  grave  import.  Delirium 
or  coma  usually  heralds  a  rapidly  fatal  termination.  The  most  significant  sign 
is  probably  the  wasting  ;  prognosis  improves  or  depreciates  with  the  patient's 
weight. 

Cases  supervening  on  a  chronic  goitre  are  usually  mild  in  type. 

It  is  almost  impossible  to  foretell  how  long  a  patient  will  be  ill.  Six  to 
eighteen  months  is  a  very  ordinary  time,  but  many  cases  drag  on  for  years.  When 
the  weight  is  steadily  falling,  the  outlook  is  less  favourable  ;  when  it  is  steadily 
rising,  the  patient  is  usually  within  a  few  months  of  the  end  of  her  troubles. 

A  few  cases  are  on  record,  especially  in  children,  in  which  the  symptoms  came 
on  rapidly  in  a  day  or  two,  and  as  suddenly  disappeared  after  a  few  weeks  or 
less.     As  a  rule,  children  do  better  than  adults,  and  women  better  than  men. 

It  is  quite  common  for  some  degree  of  permanent  indurative  swelling  of  the 
thyroid  and  slight  prominence  of  the  eyes,  due  to  fatty  accumulation  in  the 
orbits,  to  persist  even  after  recovery. 

References. —  ^Hale  White,  Guy's  Hospital  Reports,  vol.  Ixv.,  1911,  p.  i;  ^Rogers, 
Annals  of  Surgery,  Dec.  1909,  p.  1023  ;  ^Jackson  and  Eastman,  Boston  Med.  and  Surg. 
Journal,  vol.  163,  1910,  p.  419  ;  *Mackenzie,  Allbuit's  System  of  Medicine,  vol.  iv.  part  i. 
P-  377  ;  ^Stoney,  British  Medical  Journal,  1912,  ii.  p.  476  ;  *Boisson,  Etude  critique 
des  interventions  sur  le  sympathique  cervical  dans  la  nialadie  de  Basedow.  Paris,  H.  Jouve, 
1898;  ^Mayo,  Annals  of  Surgery,  1909,  vol.  i.,  p.  1018  ;  *Kocher,  Lancet,  1912,  i. 
p.  576  ;  *Kuttner,  Revue  de  Chirurgie,  1911,  p.  1031  ;  ^"Berry,  Lancet,  1913,  i,  pp.  583, 
668.  A.  Rendle  Short. 

EXTRA-UTERINE  GESTATION.— (5ee  Ectopic  Pregnancy.) 
FACIAL  PALSY. — [See  Nerve  Injuries.) 
FIBROIDS. — (See  Uterus,  Fibroids  of.) 

FRACTURES. 

Simple  Fractures. — Before  entering  on  a  detailed  consideration  of  the  end- 
results  of  various  fractures,  it  may  be  well  to  emphasize  the  fact  that  surgeons 
and  practitioners  for  some  years  have  had  a  growing  consciousness  that  the 
available  methods  of  treatment  have  not  always  yielded  results  which  can  be 
described  as  satisfactory.  It  is  platitudinous,  but  nevertheless  true,  to  say 
that  the  utility  of  a  bone  after  a  solution  of  its  continuity  depends  in  a 
measure  on  the  nature  and  extent  of  the  traumatism.  If  this  is  severe,  then 
a  complete  reconstitution  with  a  good  functional  result  cannot  always  be 
expected. 

It  is  quite  obvious  that  there  has  been,  and  is,  a  constant  effort  to  obtain  good 
results  on  the  non-operative  side,  operative  methods  apart  for  the  moment, 
as  witness  the  wonderful  inventions  which  lumber  up  the  splint  rooms  of 
hospitals,  rusty  worm-eaten  evidences  of  the  difficulty  and  disappointment 
which  attend  treatment.  Nearly  thirty  years  ago,  M.  Lucas-Championniere' 
began  to  issue  his  protest  against  rigid  and  prolonged  splint  or  plaster  fixation  : 
he  remained  until  his  death  the  grand  protagonist  of  the  school  of  treatment  by 
mobilization  and  massage.  Few  now  apply  this  method  in  its  entirety,  but 
all  recognize  its  great  importance  as  an  accessory  to  any  mode  of  treatment. 

The  extension  methods  of  Bardenheuer  are  becoming  more  known  in  this 
country,  and  those  who  have  mastered  the  application  of  the  apparatus  speak 
highly  of  the  results. 

The  nail- extension  method  of  Steinmann  would  appear  to  take  a  place 
between  non-operative  and  operative  practice,  but  its  employment  does  not 
seem  to  be  sufficiently  general  at  present  to  enable  an  opinion  to  be  formed. 


FRACTURES  175 


Ewald^  issues  a  word  of  caution  in  respect  of  this  method  ;  he  says  that  the 
results  from  the  point  of  view  of  the  fracture  were  satisfactory  if  not  brilUant. 
He  has  used  the  nail  in  29  cases  of  fracture  of  the  lower  limb;  in  18  cases  the 
perforations  healed  in  from  two  to  four  weeks,  but  in  9  cases  he  has  had  an 
infection  which  lasted  from  five  to  twelve  months,  and  in  one  case  it  was  neces- 
sary to  open  an  abscess  at  the  end  of  two  years.  Ewald  also  warns  us  against 
using  too  large  a  nail  in  the  calcaneum,  and  observes  that  the  nail  must  be 
exactly  in  the  middle  of  the  bone  or  there  is  risk  of  fracture. 

A  new  school  has  evolved  which  contends  that  accurate  anatomical  reconsti- 
tution,  and  consequential  good  functional  results,  can  best  be  achieved  by 
operative  treatment.  This  school,  most  ably  led  by  Sir  Arbuthnot  Lane,  Dr. 
Lambotte,  and  others,  energetically  rejects  for  many  fractures  the  non-operative 
and  the  older  operative  methods,  and  bases  its  case  on  the  application  of  a 
plate,  screw,  encircling  wire,  fixateur,  or  intramedullary  splint  to  the  fracture, 
accurately  reduced  by  free  incision. 

These  differing  systems  of  treatment  show  that  all  is  not  well  and  that 
prognosis  must  be  guarded. 

The  new  light  on  the  subject  afforded  by  radiography  and  the  enquiries 
under  the  Workmen's  Compensation  Acts  reveal  the  good  or  bad  results  of 
the  various  methods.  The  report  of  the  late  Mr.  Clinton  Dent,^  "  On  the  After- 
Effects  of  Injuries,"  in  which  he  states  that  he  had  difficulty  in  remembering 
a  case  of  Pott's  or  Dupuytren's  fracture  which  had  sufficiently  recovered  to 
resume  police  work,  came  as  a  shock  to  the  profession. 

The  universal  desire  for  an  inquiry  into  the  ultimate  results  obtained  in 
the  treatment  of  simple  fractures  was  voiced  at  the  meeting  of  the  Surgical 
Section  of  the  British  Medical  Association  in  London,  1910.  Pursuant  to  a 
resolution  there  passed,  the  Council  of  the  Association  appointed  a  Committee, 
whose  report  appeared  in  the  British  Medical  Journal,  November,  1912.  In 
this  report  we  have  contrasted  non-operative  and  operative  methods,  and 
it  must  form  the  basis  of  any  discussion  on  the  prognosis  of  fractures  for 
some  time  to  come.  The  number  of  cases  on  which  the  report  is  founded  is 
2940  ;  this  does  not  include  the  cases  investigated  abroad,  which  are  set  out 
separately. 

Amongst  the  important  conclusions  of  the  Committee,  one  finding  stands  out 
prominently,  taking  operative  and  non-operative  cases  together,  namely,  that 
if  a  good  functional  result  is  to  follow,  a  good  anatomical  position  must  be 
attained.  We  find  good  functional  use  accruing  in  90-7  per  cent  of  cases  when 
this  latter  is  achieved.  When  the  anatomical  results  are  moderate  or  bad,  we 
find  only  29-7  per  cent  of  good  functional  results.  When  the  anatomical 
results  are  bad,  we  note  53-3  per  cent  of  bad  functional  results.  This 
shows  the  importance  of  endeavouring  to  obtain  a  good  anatomical  recon- 
stitution. 

A  consideration  of  the  age-group  tables  in  the  report  affords  further  useful 
information.  In  the  non-operative  cases  under  15  years  of  age  there  was  a 
good  functional  result  in  90-8  per  cent,  as  compared  with  45-4  per  cent  in  cases 
over  15. 

In  the  operative  cases  belonging  to  the  class  in  which  operation  was  decided 
on  at  once  and  performed  as  soon  as  practicable,  we  find  that  under  15  years 
there  was  a  good  functional  result  in  93-6  per  cent.  In  those  over  15  years, 
operation  gave  a  good  functional  result  in  66-3  per  cent.  This  shows  the  distinct 
superiority  of  operative  as  compared  with  non-operative  methods.  The 
operative  cases  are  few  relatively  to  the  non-operative  ;  hence  it  is  not  advisable 
to  dogmatize  on  the  greater  excellence  of  operative  results.     Still,  it  may  be 


176 


INDEX     OF     PROGNOSIS 


assumed  that  as  the  older  operative  methods  on  the  long  bones,  such  as  wiring, 
etc.,  become  discarded,  and  more  operative  cases  become  available  for  com- 
parison, even  better  results  may  be  looked  for  in  the  future. 

Dujarier*  reports  that  in  32  cases  of  operative  intervention  for  fractures  of 
the  leg,  recent  or  old,  he  has  not  had  a  check  ;  all  his  patients  are  consolidated 
and  walking.     The  operations  were  carried  out  between  1904  and  1912. 

Fredet^  records  his  experience  of  operation  in  20  cases,  following  the  technique 
of  Lambotte  ;    he  expresses  himself  as  fully  satisfied  with  the  results. 

The  method  of  inserting  a  bone-graft,  generally  from  the  tibia,  in  ununited 
fractures  is  coming  into  favour,  due  very  largely  to  the  peculiarly  attractive 
advocacy  of  J.  B.  Murphy.     Albee^  reports  15  successful  cases. 

In  Table  VI  of  the  Committee's  report,  given  below,  three  fractures  are 
considered,  and  the  percentages  of  good  functional  results  (apart  from  con- 
sideration of  the  anatomical  result)  are  given.  It  will  be  seen  that  there  is 
a  diminishing  number  of  good  results  in  each  group  as  age  increases.  In  the 
words  of  the  report,  "  there  is  a  progressive  depreciation  of  the  functional 
result  of  non-operative  treatment  as  age  advances ;  the  older  the  patient  the 
worse  the  result." 


Table  VI. — Percentages  of  Good  Functional  Results  for  each  Age  Group. 

(Three  Fractures.) 


Tibia 

AND 

Fi 

BULA. 

Radius 

AND  Ulna. 

Pott's. 

Shafts. 

Shafts. 

Ages 

per  cent 

Ages 

per  cent 

Ages 

per  cent 

0-10 

93 

0-10 

72 

0-10 

. 

100 

11-15 

- 

- 

95 

11-15 

52 

11-15 

- 

100 

16-20 

- 

81 

16-20 

50 

16-20 

- 

50 

21-25 

- 

- 

77 

21-25 

50 

21-25 

- 

54 

26-45 

- 

- 

65 

26-45 

28 

26-45 

- 

54 

46-60 

- 

- 

57 

46-60 

28 

46-60 

- 

38 

61- 

- 

- 

50 

61- 

- 

30 

In  the  tables  which  follow,  when  cases  are  spoken  of  as  having  a  good 
anatomical  and  a  good  functional  result,  it  means  that  the  result  is  perfect, 
or  nearly  so.  The  result  we  should  all  aim  at  is  a  good  anatomical  and  a 
good  functional  restoration  of  a  limb.  The  percentage  of  these  achieved 
by  non-operative  and  operative  treatment  will  be  readily  found  in  the  tables, 
and  those  who  require  this  high  standard  in  their  work  will  turn  to  the  figures 
headed  "Good  Anatomical  and  Good  Functional  Results." 

In  reference  to  the  prognosis  of  fractures  in  the  neighbourhood  of  joints, 
the  recent  important  thesis  of  M.  Siauve''  contains  the  following- cogent  conclu- 
sions :  — 

The  prognosis  of  intra-  and  juxta-articular  fractures  is  most  grave.  Those 
involving  the  ankle,  wrist,  and  elbow  have  as  a  result  more  or  less  functional 
weakness,  the  cause  of  this  being  imperfect  co-aptation  of  the  fragments  and 
the  resulting  exuberant  or  vicious  callus  which  destroys  the  normal  play  of  the 
articular  surface.  The  insufficiency  of  ordinary  treatment  is  thereby  demon- 
strated. In  the  hands  of  specialists  the  ordinary  measures  may  sometimes 
be  sufficient,  but  no  matter  in  whose  hands,  the  results  are  often  bad.  Surgical 
treatment  should  be  undertaken  more  often  than  is  usually  done.  The  reason 
this  latter  is  not  generally  accepted  is  because  the  surgery  of  bones  is  far  from 
having  arrived  at  perfection,  especially  that  which  concerns  articular  and  juxta- 
articular  fractures.  This  method  is  capable  of  being  perfected,  and  will  be  in 
the  future.  The  usual  methods  have  said  their  last  word,  and  remain  to-day 
as  they  have  for  long  been — insufficient. 


FRACTURES  177 


Whether  or  not  these  weighty  words  will  be  modified,  the  future  experience 
of  surgeons  and  practitioners  alone  will  declare.  For  the  present  the  older  or 
non-operative  methods  remain  "  safe  and  serviceable."  Truly  the  results  are 
not  of  the  best ;  accurate  reconstitution,  at  any  rate  in  adults,  cannot  always 
be  attained  and  maintained.  Patients  will  be  satisfied  with  fair  functional 
results,  and  practitioners  will  hesitate  to  recommend  a  cutting  operation.  That 
the  operative  method  offers  the  nearest  approach  to  scientific  accuracy  in 
reconstruction  there  can  be  no  doubt ;  at  present  it  is  in  the  hands  of  experts, 
but  with  a  more  general  diffusion  of  knowledge  the  treatment  will  be  more 
widely  applied. 

A  criticism  put  forward  by  some  opponents  of  the  operative  method,  but 
which  is  not  yet  proved,  is  that  there  is  greater  delay  in  the  process  of  consolida- 
tion than  under  non-operative  methods.  Even  if  this  turned  out  in  the  event 
to  be  correct,  it  can  hardly  be  a  serious  objection,  as  it  would  seem  to  be  more 
important  that  a  workman  should  return  to  work  with  a  straight,  well-reconsti- 
tuted limb,  even  after  a  somewhat  longer  convalescence,  than  to  return  earlier 
with  an  irregular  and  consequentially  weak  limb,  with  the  greater  probability 
of  a  breakdown. 

On  examining  the  report  of  the  Fractures  Committee  more  closely,  it  will 
be  seen  that  the  non-operative  treatment  of  fractures  of  the  shafts  of  the  long 
bones  in  children  under  15  years  (excepting  fractures  of  both  bones  of  the  fore- 
arm) shows  a  high  percentage  of  good  results,  so  it  appears  that  operation  is 
not  a  necessity  in  children.  The  Committee  points  out  that,  as  previously 
indicated,  the  operative  cases  submitted  for  examination  were  few  in  comparison 
with  the  non-operative  cases,  and  that  it  is  undesirable  on  this  ground  to  arrive 
at  a  verdict  as  between  operative  and  non-operative  methods.  But  if  we  take 
the  operative  cases  as  they  are  set  out,  we  find  that  in  cases  treated  by  immediate 
operation,  the  deleterious  influence  of  age  upon  functional  results  is  less  marked. 
In  most  of  the  age  groups,  operative  treatment  gives  a  greater  number  of  good 
results  than  non-operative  treatment. 

Another  very  definite  finding  of  the  Committee  is  that  operative  treatment 
should  not  be  regarded  as  a  method  to  be  employed  in  consequence  of  the 
failure  of  non-operative  methods,  as  the  results  of  secondary  operations  (that 
is  to  say,  operations  on  (i)  cases  in  which  there  has  been  failure  to  obtain  and 
maintain  accurate  apposition  by  means  of  external  mechanical  appliances,  or 
(2)  cases  of  non-union,  deficient  or  faulty  union)  compare  very  unfavourably 
with  cases  in  which  operation  was  carried  out  as  soon  as  practicable  after  the 
accident. 

With  regard  to  the  important  question  of  mortality,  in  fifteen  hospitals  11,946 
fractures  of  the  long  bones  were  treated  non-operatively,  giving  a  death-rate 
of  I  per  cent.  The  majority  of  the  deaths  were  due  to  age,  disease,  or  associated 
injuries.  The  number  of  cases  treated  by  operation  was  1,040,  giving  a  death- 
rate  of  0-77  per  cent. 

The  causes  which  in  the  non-operative  cases  led  to  a  fatal  result  caused 
death  in  5  of  the  operative  cases.  The  death-rate  directly  due  to  operation 
is  then  0-3  per  cent.  Dr.  Lambotte's  death-rate  in  567  operations  is  1-5  per 
cent ;  amongst  these  he  includes  operations  for  fracture-dislocation  of  the 
iliac  bone,  multiple  fracture  of  the  leg,  double  fracture  of  the  femur,  and  a 
case  of  irreducible  subtrochanteric  obstetrical  fracture  of  the  femur  in  an 
infant  six  days  old.  Another  case  had  appendicitis  and  evacuation  of  pus 
per  anum.  Most  of  the  deaths  are  associated  with  the  injuries,  accidental  or 
avoidable. 

We  will  now  examine  the  Committee's  report  in  some  detail. 

12 


178 


INDEX     OF     PROGNOSIS 


Femur. — 

Results  of  Non-operative  and  Immediate  Operative  Treatment  of 
Fractures  of  Femur. 


1 

Good 

Poor 

Site  of  injury 

Treatment 

Cases 

anatomical  and 
functional 

anatomical, 

good 
functional 

per  cent 

per  cent 

Neck . .      -          -          -\ 

Non-operative    - 

91 

16-4 

9-8 

Operative 

1 

100 

— 

Separated    epiphysis 

of  head 

Non-operative    - 

9 

44-4 

22-2 

( 

Non-operative,  all  ages      - 

96 

54-1 

4-2 

Upper  third  of  shaft . 

Ditto,  under  15 

47 

87 

8 

1 

Operative  (all  under  15)    - 

3 

100 

— 

1 

Non-operative,  all  ages 

436 

67-8 

13-2 

Ditto,  under  15 

328 

87 

7-8 

Mid.  third  of  shaft  "  -, 

Operative,  all  ages    - 

27 

92-5 

i 

Ditto,  under  15 

25 

96 

— 

Lower  third  of  shaft  J 

Non-operative,  all  ages 
Ditto,  under  15 

104 
50 

58-6 
86 

15-3 
8 

1 

Operative,  under  20  - 

2 

50 

— 

•i     ( 

Non-operative,  all  ages 

12 

41-6. 

8-3 

Lower      extremitj',  J 

Ditto,  under  15 

2 

100 

involving  knee       -1 

Operative 

1 

a  moderate 
result  only 

If  we  consider  the  figures  of  other  authorities,  we  find  Scudder^  reporting  on 
1 6  cases  of  fracture  of  the  neck  of  the  femur  treated  by  traction  and  immobiliza- 
tion. The  cases  were  examined  two  and  a  half  to  twenty-four  and  a  half  years 
after  the  accident ;  ages  between  forty- two  and  over  sixty  ;  14  of  the  16  had 
impairment  of  function;  2,  that  is,  12-5  per  cent,  gave  good  functional  results. 
In  Walker's^  report  of  112  cases,  18  died  within  a  week  of  admission  to  hospital, 
32  not  traced  ;  of  the  remaining  62,  only  10  had  completely  recovered,  that  is, 
about  16  per  cent  of  good  functional  results.  Ashhurst  and  Newell^"  give  the 
end-results  of  21  cases  of  fracture  of  the  neck  of  the  femur  treated  conserva- 
tively ;    5,  or  23-8  per  cent,  had  a  perfect  functional  result. 

From  this  we  conclude  that  26  per  cent  of  good  functional  results  is  the  best 
we  can  expect  from  non-operative  treatment  in  adults. 

Scudder's*  statistics  of  35  cases  of  fracture  of  the  shaft  of  the  femur  treated 
non-operatively  by  Buck's  extension,  outside  T  splint,  or  long  Desault  apparatus 
and  later  plaster,  show  that  of  16  cases  between  eighteen  and  forty-eight  years, 
5  had  a  perfect  result ;  in  5  cases,  the  average  age  being  fifty-eight  years,  none 
had  a  functionally  perfect  result.  Of  14  cases,  the  average  age  being  seven  and 
a  half  years,  all  had  functionally  perfect  results  ;  4  mention  slight  pain  occasion- 
ally, and  these  have  a  little  stiffness  of  the  knee. 

This  gives  a  good  functional  result  in  about  24  per  cent  over  eighteen  years. 

Lambotte's  report  shows  13  cases  of  immediate  operation  for  fractures  of 
the  femur;  10  had  a  good  anatomical  and  a  good  functional  result,  2  a  good 
anatomical  and  moderate  or  bad  functional  result.  That  is  to  say,  a  good 
functional  result  is  achieved  in  76-9  per  cent  of  cases  operated  on. 

Walker^i  records  21  cases  of  operation  for  fractured  femur  ;  operation  was 
only  performed  after  the  best  efforts  of  conservative  treatment  had  failed.  The 
Lane  technique  was  carried  out,  Semon  extension  apparatus  and  plaster  case 
applied.  No  mortality  or  serious  complication ;  in  one  case  the  plate  was 
removed  for  slight  superficial  suppuration.  Improvement  has  resulted  in 
every  case. 


FRACTURES 


179 


Average  Duration  of  Incapacity. 


Age 

Site  of  Injury 

Non-operative 

Immediate  operation 

1 

Upper  epiphysis  and  neck 

26-5  weeks 

No  record 

Under  fifteen 

Shaft         -        -        -        - 

16-5     „ 

16-2  weeks 

years 

Lower  extremity 

]-       18-2     „ 

No  record 

Lower  epiphysis 

i 

Upper  epiphysis  and  neck 

53-2     ,, 

Over  fifteen 

Shaft          -        -        -        - 

33-6     „ 

52  weeks 

years 

1 

Lower  extremity 
Lower  epiphysis 

I       18-7    „ 

26        „ 

Permanent 

( 

Upper  epiphysis  and  neck 
Shaft         -        -        -        - 

30  per  cent 
11-7    „ 

No  record 
None 

incapacity  over 
15  years 

( 

Lower  extremity 
Lower  epiphysis 

}    -    •• 

None 

The  table  of  permanent  incapacity  is  made  up  from  252  non-operative  cases, 
and  a  very  small  number  of  operative  cases,  useless  for  purposes  of  comparison. 

Patella. — The  prognosis  in  stellate  and  longitudinal  or  subaponeurotic 
fractures  is  usually  good  under  early  massage  and  movement  treatment.  Trans- 
verse fractures  with  separation  or  the  interposition  of  aponeurotic  tags  between 
the  fragments  have  a  more  serious  outlook  as  regards  restoration  to  full  function. 

Helfericy^  (1899)  quotes  Bahr's  report  on  44  old  cases  averaging  four  years 
after  the  injury.  In  42  some  weakness  remained,  amounting  to  35  per  cent  of 
working  power ;    this  is  4-5  per  cent  good  results. 

Bull's^^  report  (1890)  is  a  vast  improvement ;  16  cases  are  recorded  ;  he  states 
that  14  of  these,  or  87-5  per  cent,  had  '  excellent '  results.  They  were  all  treated 
by  plaster-of- Paris  splints,  with  appropriate  confinement  of  the  fragments. 

Lucas-Championniere,  who  applied  his  method  of  massage  and  mobilization 
to  most  fractures,  held  that  the  treatment  is  only  of  exceptional  application 
in  fractures  of  the  patella  ;  as  a  general  rule,  suture  was  his  method  of  choice, 
for  the  reason  that  it  brings  about  a  definite  anatomical  restoration. 

Power's^*  {1898)  collection  of  711  cases  operated  on,  exhibits  a  mortality  of 
1-4  per  cent.  The  late  results  showed  94  per  cent  of  satisfactory  results,  3  per 
cent  had  marked  stiffness  and  disability,  i  per  cent  total  ankylosis. 

Stimson^^  (1910)  records  200  operative  cases  in  two  series.  First  series:  40 
cases ;  2  became  infected,  with  resulting  stiffness.  Second  series :  all  recovered 
without  accident,  with  good  use  of  joint,  99  per  cent  good  results. 

Lockwood^^  (191 1)  reports  39  operations  on  38  patients,  ages  twenty-two  to 
sixty-three.  The  wires  had  to  be  taken  out  in  2  cases  ;  skiagrams  were  available 
in  12,  and  of  these  11,  or  91-6  per  cent,  had  good  bony  union  and  good  limbs. 
He  IS  strongly  in  favour  of  operation,  as  it  gives  better  results  in  a  shorter  time. 

Delatour^''  (1914)  gives  an  account  of  99  operations:  of  these,  6  patients 
have  useful  joints,  but  with  limited  motion  ;  40  have  flexion  to  at  least  a 
right  angle,  and  have  perfectly  useful  joints.  The  remainder  were  not  traced  ; 
all  had  good  motion  to  at  least  45  degrees  when  they  left  hospital,  and  a 
satisfactory  result  was  expected. 

There  can  be  no  doubt  that  in  transverse  fractures  with  separation,  operation, 
apart  from  the  definite  though  small  risk  of  sepsis,  will  give  the  only  chance 
of  bony  union,  and  so  contribute  materially  to  a  good  functional  result.  Under 
operative  treatment  the  period  of  incapacity  will  be  from  two  to  three  months  ; 
under  conservative  treatment  from  six  to  twelve  months. 


INDEX     OF     PROGNOSIS 


Constitutional  disease  or  age  may  decisively  iniiuence  the  selection  of  con- 
servative methods. 

Refracture. — Corner's^^  paper  puts  this  matter  very  clearl}^.  After  stating 
that  the  patella  is  the  most  frequently  refractured  bone  in  the  body,  he  points 
out  that  this  occurs  most  often  between  the  ages  of  thirty  and  forty.  After 
operation,  69  per  cent  of  refractures  occur  in  the  first  year ;  after  non-operative 
treatment,  86  per  cent  of  refractures  occur  after  the  first  year.  The  percentage 
of  refractures  is  approximately  the  same  after  operative  as  after  non-operative 
treatment. 

Tibia  and  Fibula. — 

Results  of  Non-operative  and  Immediate  Operative  Treatment  of 

Fractures. 


Good 

Poor 

Site  of  Injury 

Treatment 

Cases 

anatomical 
and 

anatomical, 
good 

Junctional 

functional 

per  cent 

per  cent 

( 

Non-operative,   all  ages 

424 

74-4 

10-7 

Shaft  of  Tibia 

■ 

Ditto,  under  15 
Operative 

223 
17 

95 
76-4 

2 

17-6 

V 

Ditto,  under  15 

7 

100 

— 

Shaft  of  Fibula 

-  1 

Non-operative,  all  ages 
Operative 

"1 

70-5 
100 

3-9 

Non-operative,  all  ages 

548 

44-4 

25-6 

Ditto,  under  15 

116 

94 



Both  bones     - 

Operative,   all  ages     - 

22 

63-6 

4-5 

Ditto,  under  15 

2 

100 

— 

Non-operative,  all  ages 

246 

37-5 

10-4 

Pott's  Fracture 

Ditto,  under  15 

8 

87-5 

12-5 

Operative,  all  ages    - 

4 

50 

—    ■ 

Lambotte's  figures  for  immediate  operative  cases  of  fractured  tibia  show  5, 
with  4  good  anatomical  and  good  functional  results,  and  one  with  moderate 
or  bad  anatomical  and  good  functional  result ;  that  is,  100  per  cent  of  good 
functional  results  after  operation. 

Lambotte's  statistics  of  18  cases  of  fracture  of  both  bones  show  a  good 
functional  result  by  operation  in  95  per  cent.  Of  35  cases  operated  on  for 
failure  to  maintain  apposition,  non-union,  defective  or  faulty  union,  8  had  a 
good  anatomical  and  21  had  a  good  functional  result;  that  is,  a  percentage 
of  60  good  functional  results. 

In  Bardenheuer's  account  of  149  cases  of  ankle  fractures  generally,  77-2  per 
cent  recovered  before  ninety-one  days ;  20  had  passed  the  fiftieth  year ;  half  of 
these  had  fracture  of  both  bones ;    19  of  the  20  had  become  fit  for  work. 

Bardenheuer  points  out  that  this  good  result  in  older  people  should  be  taken 
as  proof  of  the  excellence  of  his  extension  bandage. 

Hitzrot^^  traced  64  non-operative  cases  of  Pott's  fracture  one  year  after 
injury.  Thirty-eight  cases  were  under  thirty -five  years,  and  all  had  perfect 
functional  results.  Of  12  between  thirty -five  and  fifty  years,  "  function  was 
perfect  in  all  the  cases,  extension  was  normal,  but  there  was  distinct  limitation 
of  flexion  in  all."  Of  14  between  fifty-five  and  sixty-four  3'ears,  "  function 
was  perfect  in  4  only,  5  had  practically  a  stiff  joint.  Flexion  and  extension 
were  limited  in  all." 

Chaput,-"  in  a  careful  study  of  30  cases  of  malleolar  fractures  treated  non- 
operatively,  notes  only  7  good  results  (23-3  per  cent),  4  fairly  good,  9  moderate, 
and  10  bad. 


FRACTURES 


Of  6  cases  where  operation  was  undertaken  after  the  failure  of  external 
mechanical  methods,  non-union,  faulty  or  defective  union,  i  had  a  good  anato- 
mical and  I  a  good  functional  result,  3  had  a  bad  anatomical  and  3  a  bad 
functional  result. 


Average  Duration 

OF  Incapacity. 

Age 

Site  of  Injury 

Kon-operative 

Immediate  operation 

Shafts       .... 

12-8  weeks 

9  weeks 

Under  fifteen    J 

Lower     epiphysis,     Pott's 

years           \ 

fracture 

'>2 

No  record 

Over  fifteen     j 

Shafts       .... 

26-7 

31-2  weeks 

Lower     epiphysis,     Pott's 

years            [ 

fracture 

23-7 

14-5 

Permanent      ( 

Shaft         .         .         .         . 

8"1  per  cent 

9  per  cent 

incapacity  over  \ 

Lower  epiphysis  and  Pott's 

fifteen  years      \ 

fracture 

6 

25  per  cent  bad 
results 

The  non-operative  cases  number  in  all  797,  and  the  immediate  operative 
only  26,  so  the  value  of  the  table  lies  in  the  non-operative  side. 

Astragalus. — The  table  constructed  by  G.  Gayet^^  gives  the  results  of  the 
operative  treatment  of  fractures  of  the  astragalus.  If  there  is  no  displacement, 
or  if  displacement  and  the  fragments  are  easily  reduced  and  maintain  their 
position,  massage  and  early  movements  will  in  all  probability  give  a  good 
r^ult. 

If  there  is  much  displacement  of  fragments,  partial  or  complete  removal  of 
the  bone  will  be  required. 

Of  22  cases  up  to  the  age  of  sixty-four  years  in  which  complete  removal  of 
the  bone  was  performed,  21  (95-9  per  cent)  gave  a  good  result  in  the  sense  that 
the  patient  was  able  to  return  to  his  occupation  ;  the  bad  result  was  in  a  case 
operated  on  eight  months  after  the  fracture.  Of  10  cases  of  partial  removal, 
1(10  per  cent)  only  gave  an  excellent  result,  i  a  satisfactory  result,  and  i  returned 
to  work,  but  was  quickly  fatigued. 

Cabot  and  Binney--  give  figures  in  respect  of  8  cases.  There  was  a  good 
result  in  25  per  cent  and  a  bad  result  in  75  per  cent,  and  they  conclude  that 
the  results  are  distinctly  worse  than  in  fracture  of  the  calcaneum.  The  average 
period  of  disability  was  about  a  year  and  a  half.  In  making  a  prognosis  from 
an  x-TZ-Y  photograph  in  cases  of  fracture  of  the  astragalus,  it  is  well  to  remember 
that  the  posterior  surface  of  this  bone  has  a  small  tubercle,  the  os  trigonum, 
which  occasionally  has  a  separate  existence  and  so  simulates  a  fracture. 

Calcaneum. — Three  forms  of  this  fracture  are  recognized  :  (i)  Posterior 
portion  with  iendo  A  chillis  ;    {2)  Comminution  of  body  ;    (3)   Sustentaculum  tali. 

In  the  first  form  there  is  not  usually  much  separation  of  the  fragments  ; 
but  if  there  is,  then  operation  and  fixation  by  a  screw  will  give  the  best  results. 
In  the  second  form,  accurate  anatomical  reposition  is  not  generally  feasible. 
Operation  may  be  required  to  remove  fragments ;  in  any  case  the  results  are 
very  unsatisfactory.  In  the  third  form,  there  generally  results  an  amount  of 
aversion  and  sinking  of  the  inner  border  of  the  foot. 

In  all  the  forms  there  frequently  follows  pain  in  the  foot  and  difficulty  in 
walking,  consolidation  of  the  fracture  itself  is  much  delayed,  and  no  weight 
should  be  borne  on  the  foot  for  at  the  least  two  months. 

Ely^^  records  12  cases  of  fracture  of  the  calcaneum,  and  in  i  only  was  the 
result  good  (8-6  per  cent). 


1 82  INDEX     OF     PROGNOSIS 

Cabot  and  Binney's^^  statistics  of  26  cases  show  good  result  in  50  per  cent, 
fair  in  38  per  cent,  and  bad  in  12  per  cent. 

These  good  results  seem  to  be  quite  above  the  average,  and  appear  to  be 
accounted  for  by  the  fact  that  7  were  heel-fragment  cases,  and  that  5  of  these 
had  good,  and  i  a  fair  result.  The  average  duration  of  disability  was  about 
six  months.  This  period  appears  short,  probably  on  account  of  the  number  of 
heel-fragment  cases  in  the  series. 

Cuboid. — Fracture  of  this  bone  is  rare,  and  there  is  not  generally  great  dis- 
placement of  fragments,  though  the  fracture  is  usually  a  comminuted  one. 
A  good  result  may  be  expected. 

Tarsal  Scaphoid. — Isolated  fracture  of  this  bone  is  not  so  ver^^  rare,  and  a 
considerable  number  of  cases  have  been  reported.  It  is  difficult  to  maintain 
the  fragments  if  much  displaced,  or  even  to  reduce  them ;  but  if  this  can  be 
effected,  then  a  good  result  vdW  probably  follow.  In  cases  where  the  fragments 
cannot  be  reduced,  removal  by  operation  is  indicated. 

Macausland  and  Wood-*  report  2  cases  of  between  five  and  six  months' 
standing,  of  complete  removal  of  the  scaphoid  for  fracture,  with  a  good  functional 
result  in  both. 

Abadie  and  Rauge-^  report  28  cases  ;  of  the  15  in  which  the  result  is  men- 
tioned, 4  were  operated  on,  and  3  of  these  had  a  good  result;  11  were  treated 
non-operadvely,  and  3  had  a  good,  4  a  moderate,  and  4  a  bad  result.  The 
tubercle  of  the  scaphoid  is  occasionally  fractured  by  muscular  action,  such  as 
dancing,  and  a  valgus  condition  may  ensue.  In  forming  an  opinion  from  a 
radiograph,  it  is  well  not  to  overlook  the  occasional  presence  of  a  sesamoid 
bone  in  the  tibialis  posticus  tendon  ;  it  might  be  taken  for  a  fracture  of  the 
scaphoid  tubercle. 

Cuneiform  Bones. — Fractures  of  these  bones  occur  in  association  -with  a 
crush  of  the  foot,  and  the  prognosis  depends  largely  on  the  damage  to  other 
parts.  If  a  readjustment  can  be  made  and  the  soft  parts  recover,  then  a  fair 
result  may  be  expected. 

Metatarsals. — Fractures  of  these  bones  may  cause  considerable  disability 
in  the  use  of  the  foot  if  a  fair  alignment  of  the  bones  cannot  be  achieved.  It 
there  is  much  displacement  of  the  fragments,  anatomical  restoration  and 
fixation  by  operation  will  give  good  results.  Fractures  united  with  marked 
upward  or  downward  displacement  frequently  cause  very  definite  disability. 

Fifth  Metatarsal  (Jones's  fracture). — An  indirect  fracture  which  occurs  by 
inversion,  treading  on  the  outer  side  of  the  foot ;  the  line  of  fracture  is  near  the 
base.  There  is  neither  crepitus  nor  deformity.  The  diagnosis  depends  on  the 
radiographs,  and  the  prognosis  is  good. 

Fractures  of  the  phalanges  are  frequently  compound,  and  the  prognosis 
depends  largely  on  whether  the  wound  infection  is  localized  or  becomes  exten- 
sive, involving  joints  and  tendon  sheaths.  In  the  former  the  result  will  be 
good,  and  in  the  latter  great  disability  will  ensue. 

Humerus. — -It  wnH  be  observed  from  the  table  opposite  that  the  results  of 
fractured  tuberosity  are  not  good,  and  it  seems  reasonable  to  expect  better  in  csises 
m  which  the  fragment  is  separate  if  it  is  fixed  into  position  by  means  of  a  screw. 

Seven  cases  of  fracture  of  the  surgical  neck,  2  being  under  ten  years,  were 
treated  by  operation  after  failure  of  non-operative  methods,  faulty  or  defective 
union.  In  all,  the  results  were  good ;  that  is,  100  per  cent  good  functional 
results.     This  seems  to  be  specially  good  operative  results  for  cases  of  this  class. 

In  13  cases  of  fracture  of  the  shaft  in  which  operation  was  undertaken  on 
account  of  failure  of  non-operative  methods,  faulty  or  defective  union,  61-5 
per  cent  had  good  functional  results. 


FRACTURES 


183 


In  6  cases  of  supracondylar  fracture,  2  being  under  ten  years,  in  which  opera- 
tion was  undertaken  for  failure  of  non-operative  methods,  faulty  or  defective 
union,  33-3  per  cent  had  good  functional  results. 

Six  cases  of  separated  lower  epiphysis  were  operated  on  for  the  same  reason  ; 
I,  or  i6'6  per  cent,  had  good  functional  result. 

In  a  case  of  fracture  of  the  internal  condyle  in  which  operation  was  undertaken 
for  failure  of  non-operative  methods,  the  functional  result  was  only  moderate. 

Results  of  Non-operative  and  Immediate  Operative  Tre.\tment 
OF  Fractures. 


Good 

Poor 

anatomica.! 

anatomical. 

Site  of  Injury 

Treatment 

Cases 

and 
functional 

good 
functional 

^^ 

per  cent 

per  cent 

Anatomical  Neck   -  -| 

Non-operative    - 
Operative  -         -         -         - 

5 
2 

80 
100 

— 

j 

Non-operative,  under  20    - 

5 

80 

20 

Upper  Epiphysis     -   - 

Operative,  under  20 

2 

100 

— 

Tuberosity 

Non-operative    - 

3 

33 

— 

( 

Non-operative,  all  ages 

37 

40 

17-5 

1 

Ditto,  under  20 

10 

100 

— 

Surgical  Neck          -   - 

Operative,  all  ages    - 

6 

60 

— 

1 

Ditto,  under  20 

2 

100 

— 

f 

Non-operative,  all  ages 

68 

64-5 

21-9 

Shaft     -          -         -  -, 

Ditto,  under  15 

18 

61 

22 

Operative,  all  ages 

6 

83-3 

— 

Supracondvlar         -   \ 

Non-operative,  all  ages 

17 

41-1 

11-1 

Ditto,  under  15          - 

8 

75 

12-5 

V 

Operative,  under  15    - 

1 

100 

— 

Lower  Epiphysis     -   ■ 

Non-operative  - 
Operative 

50 
14 

44 
57-1 

22 
71 

Internal  Condyle    -   - 

Non-operative,  all  ages 
Ditto,  under  15 

17 
11 

41-1 

72-7 

23-5 

External  Condyle   - 

Non-operative,  under  25    - 

7 

14-2 

42-8 

Musculospiral  Paralysis  occurs  in  from  4  to  8  per  cent  of  cases  of  fractures 
of  the  humerus,  being  associated  most  frequently  with  fracture  in  the  middle 
third  of  the  shaft.  The  prognosis  is  fairly  good  after  suture,  or  release,  or  both. 
Scudder  and  Paul's-*  table  of  11  cases  treated  by  operation  shows  8  cases  of 
recovery  of  function — 72-2  per  cent — -the  shortest  interval  in  the  successful 
cases  between  the  accident  and  the  operation  being  three  weeks,  and  the  longest 
three  years. 

Hitzrot's^^  statistics  refer  to  141  non-operative  cases  of  fracture  of  the 
surgical  neck  of  the  humerus.  Two  were  in  children,  i  treated  by  non- 
operative  and  the  other  by  operative  methods ;  both  had  perfect  results.  In 
the  remaining  139  cases,  hyperabduction  to  the  amount  of  5  per  cent  was  lost 
in  all  except  2  ;  external  rotation  to  the  amount  of  5  to  10  per  cent  less  than 
normal  was  present  in  all  cases. 

The  treatment  adopted  was  :'  Arm  flexed  and  held  in  a  sling,  cushion  in  axilla, 
extension  of  from  5  to  10  lb.  applied  and  allowed  to  hang  for  an  hour.  When 
fracture  is  reduced,  shoulder  plaster  splints  back  and  front  down  to  wrist ; 
;ir-ray  control,  splints  on  for  three  to  live  weeks,  massage  and  movements  at 
end  of  ten  days,  galvanic  and  faradic  currents  to  deltoid. 

Lower  End  of  Humerus. — There  were  106  cases,  all  under  ten  years  ;  51 
cases  of  fracture  of  external  condyle  in  children  treated  by  hyperflexion  for 
two   weeks,   then   massage;     in    i,  a   fragment   had   to   be   removed  ;    all  had 


184 


INDEX     OF    PROGNOSIS 


perfect  return  of  function  ;  54  cases  of  supracondylar  fracture  in  children 
reduced  under  anaesthesia,  arm  fiexed  at  right  angle  or  beyond  ;  two  cases 
had  musculospiral  paralysis  and  were  operated  on,  function  becoming  complete 
in  twenty  weeks  in  one  case,  in  the  other  not  so  satisfactory,  in  thirty-six  weeks. 

Of  these  cases,  50  had  no  perceptible  deformity;  function  of  the  elbow  joint 
was  perfect  in  all  cases.  In  34  adult  cases,  12  involved  the  external  condyle; 
1 1  were  uncomplicated  ;  all  treated  by  as  much  hyperflexion  as  possible  ;  no 
deformity  resulted ;  function  excellent,  but  not  perfect.  Six  cases  of  fracture 
of  the  internal  condyle  treated  by  reduction  under  ether  and  flexion ;  function 
excellent  in  all,  perfect  in  one. 

Fractures  of  the  Elbow. — Andre  Treves^'  gives  a  careful  account  of  the  late 
results  of  162  cases  in  children,  as  follows  : — 


Site  of  Injury 

Under  5  years 

5-10   years 

10-15  years 

Eesults 

Supracondylic 
External  condyle    - 
Simple    internal 

condyle 
T  fracture 
Lower  epiphysis 

18 
17 

1 
0 
3 

51 
21 

16 

1 
2 

10 
4 

'I 

0 

Perfect  function  in  88  per  cent 
Excellent  function  80  per  cent 

Perfect  function  61  per  cent 
Satisfactory  50  per  cent 
Perfect  function  100  per  cent 

Ten  supracondylic  cases  had  operations  for  defective  union,  and  6  for  nerve 
injuries. 

Six  internal  condyle  cases  had  operations  for  defective  union,  and  3  for  nerve 
injuries. 

Thirteen  fractures  of  the  internal  condyle  with  luxation  had  10  perfect 
results — 70  per  cent. 

These  figures  again  show  that  good  functional  results  are  obtained  in  children 
by  non-operative  methods.  Treves  says  that  the  treatment,  save  in  supra- 
condylic by  flexion  where  extension  is  required,  and  the  supracondylic  with 
lateral  displacement  where  extension  is  admissible,  should  be  by  immobiliza- 
tion in  flexion,  the  duration  of  immobilization  being  from  eight  to  fifteen  days, 
and  not  beyond  three  weeks.  Early  massage  and  movements  are  harmful, 
because  they  produce  excessive  callus  in  children,  and  besides,  they  are  very 
painful. 

Average  Duration  of  Incapacity. 


Under  j 

fifteen  years  ( 

Over  f 

fifteen  years  | 

Permanent  j 

incapacity  over  - 

fifteen  years  t 


Site  of  Injury 


Anatomical  neck  and  upper  epiphysis 

Surgical  neck  and  shaft 

Lower  epiphysis  and  supracondylic  - 

Anatomical  neck  and  upper  epiphysis 

Surgical  neck  and  shaft 

Lower  epiphysis  and  supracondylic  - 

Anatomical  neck  and  upper  epiphysis 

Surgical  neck  and  shaft 

Lower  epiphysis  and  supracondylic  - 


Kon-operative     Immediate  operatioa 


8  weeks 

No  record 

10- ■)    „ 

26   weeks 

13"5     ,, 

8-7      „ 

5-2     „ 

8 

27-6     „ 

32-8      „ 

17-1     „ 

78      .  „ 

20  per  cent 

None 

10 

8  %  bad  results 

17 

6     „ 

This  point  was  noted  in  92  non-operative  cases  and  11  operative  cases,  and, 
for  what  it  is  worth,  shows  operative  treatment  in  a  favourable  light ;  but  the 
operation  cases  are  too  few  to  base  a  reliable  opinion  upon. 


FRACTURES 


185 


Radius  and  Ulna. — 

Results  of  Non-operative  and  Immediate  Operative  Treatment  of 
Fractures  of  Radius  and  Ulna. 


Good 

Poor 

Site  of  Injury 

1  reatment 

Cases 

and 

functional 

good 
functional 

Radius,    upper    epi- 

per cent 

per  cent 

physis  - 

Non -operative,  under  15 

2 

50 



( 

Non-operative,   all  ages 

45 

53-1 

12-7 

Radius,  shaft   -         -  ' 

Ditto,  under  15 
Operative,   all  ages    - 

19 
7 

73-6 

57-1 

10-5 
14-2 

Ditto,  under  15 

4 

75 

25 

Radius,     lower     epi-J 
physis  -         -          - 1 

Non-operative,  all  ages 
Ditto,   under  15 

15 
11 

66-6 
03-6 

13-3 
9 

Operative,  under  10  - 

1 

100 

— 

\ 

Non-operative,  all  ages 

47 

27-6 

29-7 

CoUes's     - 

Ditto,  under  15 

4 

100 

— 

Operative 

1 

100 

— 

Ulna,  olecranon        -  1 

Non-operative,  all  ages 
Operative,  all  ages    - 

20 
19 

45 
73-(> 

311 
5-2 

( 

Non-operative,  all  ages 

18 

77-7 

ll-l 

Ulna,  shaft 

Ditto,   under  15 

10 

80 

10 

Operative 

1 

result  not  good 

— 

Ulna,  lower  epiphysis 

Non-operative 

3 

100 

— 

( 

Non-operative,  all  ages     - 

2 

38 

17-1 

Radius  and  ulna      -  ' 

Ditto,   under  15 

76 

63 

— 

1 

Operative,  all  ages    - 

54 

75 

— 

Ditto,  under  15 

3 

100 

Hitzrot^^  records  15  cases  of  fracture  of  the  head  of  the  radius  with  little 
displacement;  flexion  and  extension  eventually  became  complete  in  all,  but 
in  II  cases  pronation  and  supination  only  half  the  normal.  Of  4  cases  with 
displacement  of  fragments,  in  2  the  head  had  to  be  removed  in  its  entirety ; 
in  the  remaining  2  a  broken  fragment  only  was  removed.  The  functional  result 
was  best  in  the  cases  in  which  the  head  was  completely  removed,  and  not  good 
in  the  2  cases  of  partial  removal. 

In  10  cases  of  fracture  of  the  neck  of  the  radius  of  the  transverse  type  half 
an  inch  below  the  head,  2  (20  per  cent)  had  a  good  and  8  a  moderate  functional 
result. 

Average  Duration  of  Incapacity. 


Under  ( 
fifteen  years 

Over  j 

fifteen  years  ' 

Permanent  i 

incapacity  over-' 

fifteen  vears 


Site  of  Injury 

Non-operative 

Immediate  operative 

Radius  and  ulna 

17-1  weeks 

6  weeks 

CoUes's  fracture 

3-7       „ 

No  record 

Radius  and  ulna 

20-6       „ 

19'4  weeks 

CoUes's  fracture 

17-1       „ 

— 

Radius  and  ulna  (including 

lower  epiphysis)     - 

G  per  cent 

8  per  cent 

Colles's  fracture 

14-7       „ 

~~~ 

These  non-operative  cases  include  64  radius  and  ulna  fractures  and  34  Colles's, 
and  the  operative  cases  25  radius  and  ulna  and  only  i  Colles's  fracture. 

Arrest  of  growth  of  the  radius  is  to  be  found  as  an  end-result  of  separation 
of,  or  injury  to,  the  lower  radial  epiphysis. 

Poland-''  records  17  out  of  a  total  of  over  700  of  these  cases.     He  also  notes 


INDEX     OF     PROGNOSIS 


56  cases  of  arrest  of  growth  after  these  injuries,  the  radial  cases  being  the  most 
numerous.  Recently,  3  cases  have  come  under  my  own  observation ;  the 
diminished  length  of  the  radius  and  the  normal  length  of  the  ulna,  gave  the 
hand  its  characteristic  deformity.  In  only  i  of  these  3  was  the  functional 
result  good. 

Table  VII  of  the  Report  gives  a  summary  of  all  fractures  over  fifteen  years, 
and  notes  the  average  duration  of  incapacity. 


Duration  of  incapacity 

Percentage  of  cases  of  permanent  incapacity 

Non-operative,  27'f)  weeks 
Operative            27"3       ,, 

9  per  cent 
7-8 

Carpal  Scaphoid. — Hitzrot^^  records  14  cases,  7  without  displacement  of 
fragments  treated  by  a  moulded  anterior  splint,  fingers  free,  hand  in  slight 
radial  deflection  and  extension,  early  massage,  full  movement  in  sixth  week. 
The  result  was  hyperextension  limited  in  all,  flexion  in  i,  with  pain  on  movement. 
In  3  cases  Avith  displacement  of  proximal  fragment,  the  latter  was  removed  by 
dorsal  incision  and  treated  as  the  foregoing ;  result,  extension  two-thirds 
normal,  flexion  seven-eighths  normal,  deflection  less  than  normal. 

Four  cases  with  similar  displacement  associated  with  dislocation  of  the  semi- 
lunar ;  the  fragment  and  the  semilunar  were  removed  in  3  ;  the  result  was  fair. 
In  the  fourth  case  the  fragment  of  the  scaphoid  was  removed,  and  an  ineffectual 
attempt  to  reduce  the  semilunar  was  made  ;  the  result  at  the  end  of  nine  weeks 
was  a  stifi  wrist.  The  prognosis  is  not  wholly  good,  though  Cotton'^^  says  that 
in  3  of  his  cases  in  which  removal  of  fragments  was  done  in  uncomplicated 
fractures,  the  results  were  practically  perfect. 

Lambotte^°  thinks  that  in  view  of  the  unsatisfactory  results  ordinarily 
obtained,  the  fragments  could  be  readily  held  together  by  a  fine  screw  and  a 
better  result  obtained. 

Campbelpi  records  3  cases  of  fracture  of  the  carpal  scaphoid,  with  a  lesion  of 
the  median  nerve,  which  eventually  made  a  good  recovery  as  regards  the  nerve 
injury.  In  examining  a  radiograph  for  this  fracture  it  is  necessary  to  remember 
that  in  about  i  per  cent  of  persons  the  scaphoid  is  normally  divided  into  two 
parts  in  the  course  of  developm.ent ;    this  might  be  mistaken  for  a  fracture. 

Semilunar. — A  number  of  cases  of  fracture  of  this  bone  have  been  recorded 
by  Ebermayer,^-  Finsterer,^^  and  others.  It  is  a  compression  fracture.  The 
prognosis  is  not  good  as  regards  function ;  the  bone  may  require  removal  ou 
account  of  pain  and  diminished  movements  of  the  hand. 

Os  Magnum. — Fractures  of  this  bone  are  relatively  rare.  Harrigan^*  has 
collected  6  authoritative  cases,  including  one  of  his  own  ;  in  2  only  was  the 
diagnosis  confirmxed  by  ^r-rays.  The  results  do  not  seem  to  be  satisfactory. 
In  none  of  the  cases  is  it  stated  that  a  good  result  ensued. 

Fractures  of  the  Trapezium,  Trapezoid,  Unciform,  and  Pisiform  have  been 
reported.  They  are  important,  for  they  are  likely  to  be  followed  by  anky- 
losis, so  that  the  best  results  may  be  expected  from  elastic  pressure,  early 
passive  movements,  and  massage. 

Metacarpals. — Fracture  of  the  First  Metacarpal. — This  may  occur  at  the 
distal  end  of  the  shaft  or  at  the  base.  If  good  alignment  can  be  achieved  and 
maintained  in  these,  a  good  result  may  be  expected. 

Fracture  at  the  Base  (Bennett's  Fracture). — An  oblique  fracture  through  the 
base.  Good  ana'tomical  reposition  is  not  always  achieved,  but  very  fair 
functional  results  may  follow. 


FRACTURES  187 


Lambotte^"  has  had  a  good  result  by  fixing  the  fragment  into  position  with 
a  fine  screw. 

Separation  of  the  Basal  Epiphysis  of  the  first  metacarpal  occasionally  occurs. 
In  the  two  cases  recorded  by  Coues^^  a  good  result  followed. 

Fractures  of  the  Shafts  of  the  other  metacarpals  are  apt  to  give  serious  trouble 
if  a  good  alignment  cannot  be  achieved  ;  if  this  is  obtained  and  maintained,  the 
results  are  good.  In  difficult  cases,  oblique  fractures  and  such  like,  Lambotte 
recommends  a  small  form  of  fixateur  or  a  small  plate,  or  cerclage,  as  giving 
good  results. 

Fractures  of  the  Heads  (knuckle  fracture;  pugilists'  fracture). — According 
to  Cotton,-^  some  deformity  always  remains,  flexion  may  be  impaired,  function 
generally  is  good.  He  quotes  a  case  in  which  there  were  sixteen  of  these 
fractures  in  both  right  and  left  hands  without  serious  loss  of  function  occurring, 
except  in  one  knuckle. 

Fractures  of  the  Phalanges  usually  unite  well,  and  unless  the  crush,  which  is 
generally  the  cause,  is  severe,  a  good  result  follows  moderate  readjustment  of 
the  fragments. 

Fracture  of  the  Sesamoid  Bones  of  the  thumb  has  been  described  by  Preiser  ;  ^^ 
no  bony  union  followed,  but  the  functional  result  was  good. 

Scapula. — Fractures  of  the  Body  are  often  multiple.  Union  takes  place 
frequently  with  overlapping  or  exuberant  callus,  but  generally  speaking  good 
functional  results  ensue.  Cotton  states  that  in  his  10  cases  the  results  were 
practically  perfect. 

Acromion  Fracture  is  rare.  Union  may  be  fibrous  or  bony  ;  in  either  case 
the  functional  results  are  nearly  always  good. 

Spine. — The  edge  may  be  broken,  or  the  mass  of  bone,  including  the  acromion, 
may  be  separated  ;    some  deformity,  but  no  permanent  disability,  results. 

Glenoid  is  rare  except  as  an  accompaniment  of  dislocation  of  the  head  of 
the  humerus.  It  is  possible  that  chipping  off  of  the  edges  may  predispose  to 
recurrence  of  the  dislocation. 

Coracoid. — The  line  of  fracture  is  usually  well  behind  the  tip,  but  this  may  be 
split  longitudinally.  Union  is  seldom  bony,  but  there  is  no  displacement 
unless  the  coraco-clavicular  ligaments  are  torn.  Rarely  is  there  any  great 
functional  disability. 

Neck. — The  line  of  fracture  is  through  the  suprascapular  notch  to  the  axillary 
border.  Bony  union  with  some  displacement  is  the  rule.  In  the  majority  of 
cases  good  functional  results  ensue. 

Sternum, — Fractures  of  this  bone  are  usually  associated  with  damage  to 
the  intrathoracic  or  abdominal  organs,  and  the  prognosis  may  depend  on  the 
extent  of  injury  there.  Gurlt  collected  98  cases,  and  of  these  54  were  simple 
cases;  46  recovered,  8  died,  whilst  of  44  cases  complicated  by  severe  injuries, 
only  I  recovered. 

Fracture  of  the  Ensiform  Cartilage  may  occur.  It  is  sometimes  followed  by 
troublesome  vomiting,  which,  in  one  of  the  4  cases  tabulated  by  Gurlt,  persisted 
for  two  years  and  then  ceased  spontaneously.  In  three  of  the  cases,  vomiting 
ceased  when  the  depressed  cartilage  was  drawn  forward. 

Clavicle. — These  fractures  usually  unite  well ;  non-union  is  rare.  The  bond 
is  firm  at  the  end  of  four  weeks.  Displacement,  deformity,  and  shortening  are 
the  rule.  The  amount  of  shortening  may  be  as  much  as  two  inches.  These 
conditions,  however,  do  not  follow  in  those  cases  in  which  the  line  of  fracture 
is  transverse  and  where  displacement  is  absent  at  the  beginning. 

Despite  deformity  and  shortening,  the  functional  usefulness  of  the  arm  is 
seldom  much  interfered  with. 


INDEX     OF     PROGNOSIS 


The  rare  complications  of  this  fracture  which  render  the  prognosis  not  good, 
are  injuries  to  the  subclavian  artery  and  vein,  brachial  plexus,  or  lung,  and 
pressure  by  exuberant  callus.  If  operation  is  required  for  great  deformity  and 
failure  of  the  usual  treatment  to  maintain  a  correct  position,  or  for  other 
reasons,  a  screw  driven  in  longitudinally,  or  cerclage  (Lambotte's)  or  a  fine 
Lane  plate  away  from  the  skin,  will  give  good  results. 

Ribs. — Simple  fractures  without  complications  do  very  well.  If  excessive 
callus  forms  and  persists,  it  may  cause  pressure  on  intercostal  ner\^es,  and  per- 
sistent pain  may  follow.  In  old  or  feeble  persons,  the  immediate  outlook  is 
more  serious,  pneumonia  being  the  most  dangerous  sequela. 

Pelvis. — Fractures  of  the  pelvis  are  not  common,  and  the  prognosis  depends 
largely  on  the  associated  damage  to  pelvic  viscera. 

Shock  is  a  cause  of  death  in  many  cases.  If  the  patient  recovers,  there  is 
frequently  deformity,  which,  if  it  obstructs  the  pelvic  outlet  in  females,  may  be 
a  serious  matter  during  parturition.  On  the  other  hand,  in  the  lesser  injuries, 
the  results  may  be  quite  good. 

PauP'  records  a  table  of  54  cases,  with  a  mortaUty  of  50  per  cent.  Five  lapar- 
otomies were  done — four  for  ruptured  bladder  or  rectum — and  aU  died.  Four 
external  urethrotomies  were  required  ;    two  died. 

Estimation  of  Depreciation  of  Capacity  for  Work. 

On  the  Continent,  in  cases  in  which  there  is  complete  and  permanent  disable- 
ment, compensation  is  allowed  equal  to  two-thirds  of  the  wages  earned.  In 
the  United  Kingdom,  half  the  average  weekly  wage  is  paid  so  long  as  there  is 
incapacity  for  work.  The  worker  will  then  thus  receive  his  fuU  compensation, 
so  long  as  he  is  unable  to  do  any  work. 

The  following  table  is  after  Brouardel,^*  100  being  reckoned  as  the  full  estima- 
tion of  depreciation.  This  figure  is  appUed  to  such  cases  as  complete  loss  of 
vision  or  loss  of  the  use  of  two  limbs.  The  table  will  give  a  general  idea  of  the 
depreciation  in  working  capacity  in  the  various  permanent  injuries,  four  tjrpes 
of  workers  being  selected.  The  short  notes  which  follow  are  intended  to  give 
a  general  idea  as  to  the  working  capacity  after  injury  of  men  who  follow  arduous 
occupations.  The  figures  are  taken  from  Brouardel,  Rohmer^®,  OUiveet  Le 
Meignen^o,  and  others. 

Brouardel's  Table  I. 


Occupation 

Occupation 

specially 

specially 

Permanent  Infirmities  : 

Day 

requiring 

requiring 

Workers 

100  indicates  the  maximum  of  loss 

labourers 

the  use  of 

the  upper 

mbs 

the  use  of 

the  lower 

limbs 

in  the  arts 

Right  Upper  Limb. 

Loss  of  the  whole  limb       .         -         .         - 

70-80 

70-80 

50-70 

70-90 

Loss  of  the  part  below  the  elbow 

70-80 

70-80 

50-60 

70-90 

Loss  of  the  hand        -         -         -         .         - 

60-75 

05-75 

45-55 

70-90 

Loss  of  thumb  -                   .... 

2.0-35 

25-35 

15-25 

40-55 

Loss  of  index  finger  -         .          .         -         - 

10-15 

10-25 

10-15 

25-35 

Loss  of  middle  finger          .... 

10-15 

10-15 

.5-10 

.    1.5-25 

Loss  of  ring  finger      -                   ... 

5-10 

5-10 

.5-10 

1.5-20 

Loss  of  little  finger 

5-10 

.5-10 

5-10 

1.5-20 

Complete  ankylosis  of  shoulder 

40-55 

40-50 

25-35 

40-(;5 

Incomplete  ankylosis  of  shoulder  according 

to  the  degree          ..... 

10-40 

10^0 

10-25 

30-40 

Complete  ankylosis  of  elbow 

30-40 

30-35 

10-25 

35^5 

Incomplete    ankylosis    of    elbow    according 

to  degree         -         -          -         -     .    - 

10-30 

10-30 

0-10 

20-35 

Complete  ankylosis  of  ^^Tist 

20-35 

20-30 

5-15 

30-45 

FRACTURES 


189 


Brouardel's   Table   II. 


Occupation 

Occupation 

specially 

specially 

Permanent  Infirmities: 

Day 

requiring 

requu-ing 

Workers 

100  indicates  tlie  maximum  of  loss. 

laboui-ers 

the  use  of 

the  upper 

limb 

the  use  of 

the  lower 

limb 

m  the  arts 

Left  Upper  Limb. 

Loss  of  the  whole  limb      .... 

60-70 

60-70 

40-50 

70-80 

Loss  of  the  part  below  the    elbow      - 

60-70 

60-70 

40-5U 

70-80 

Loss  of  the  hand 

55-65 

55-65 

30-40 

70-80 

Loss  of  the  thumb     .         .          .         -         - 

15-25 

15-25 

10-25 

25-40 

Loss  of  index  finger 

5-15 

5-15 

5-15 

15-25 

Loss  of  middle  finger          .... 

5-10 

5-10 

5-10 

15-20 

Loss  of  ring  finger     .         -          .         -         . 

5-10 

5-10 

0-5 

10-15 

Loss  of  little  finger              .... 

0-10 

0-5 

0-5 

5-10 

Complete  ankylosis  of  shoulder 

40-50 

30-45 

10-25 

35-55 

Incomplete  ankylosis  of  shoulder~according 

to  degree         

10-40 

10-30 

0-10 

10-35 

Complete  ankylosis  of  elbow 

25-35 

25-35 

5-15 

25-40 

Incomplete    ankylosis    of    elbow    according 

to  degree         

5-25 

5-25 

0-5 

10-25 

Complete  ankylosis  of  wrist 

15-20 

15-20 

5-10 

20-30 

Incomplete  ankylosis  of  wrist  according  to 

degree   - 

5-15 

5-15 

0-5 

5-20 

Brouardel's 

Table  III. 

Occupation 

Occupation 

specially 

specially 

Permanent  Infirmities: 

Day 

requiring 

requiring 

Workers 

100  indicates  the  maximum  of  loss 

labourers 

the  use  of 

the  upper 

limbs 

the  use  of 

the  lower 

limbs 

in  the  arts 

Lower  Limbs. 

Loss  of  the  whole  limb      .         .         .         - 

50-75 

50-75 

70-90 

50-75 

Loss  of  the  limb  below  the  knee 

50-70 

50-70 

60-80 

50-70 

Loss  of  the  foot         ..... 

40-fiO 

40-60 

60-80 

50-60 

Loss  of  all  the  toes  -         .         -         .         - 

25-35 

20-30 

40-60 

25-35 

Loss  of  the  great  toe         .... 

15-20 

10-20 

20-40 

15-20 

Great  shortening  of  the  lower  limb  (above 

5  cm.) 

25-35 

20-30 

45-60 

2.5-35 

Slight  shortening  of  the  lower  limb  (below 

5  cm.) 

up  to  25 

up  to  20 

up  to  45 

up  to  25 

Complete  ankylosis  of  hip  -         -         -         . 

30-45 

30-45 

60-80 

30-35 

Incomplete  ankylosis  of  hip   according  to 

degree     

10-30 

10-30 

40-60 

10-30 

Complete  ankylosis  of  knee 

20-30 

20-30 

40-60 

20-30 

Incomplete  ankylosis  of  knee  according  to 

degree     

10-20 

10-20 

30-40 

10-20 

Complete  ankylosis  of  ankle 

10-25 

10-25 

40-60 

10-25 

Incomplete  ankylosis  of  ankle  according  to 

degree     ....... 

0-10 

0-10 

30-40 

0-10 

Fractures  at  the  Upper  End  of  the  Femur  \vliich  result  in  non-union  or  exces- 
sive callus  formation  with  interference  with  the  movements  of  the  joint,  and 
ankylosis,  may  seriously  depreciate  a  workman's  earning  capacity.  He  may 
be  compelled  to  use  a  stick,  or  even  a  crutch,  and  he  will  in  all  probability  be 
obliged  to  seek  other  employment  if  his  usual  work  required  the  full  use  of 
his  hip  joint,  as  would  be  the  case  if  the  work  involved  climbing  ladders,  etc. 
Wasting  of  muscles  is  a  frequent  accompaniment  of  partial  ankylosis,  and  adds 


I90  INDEX     OF     PROGNOSIS 

to  the  incapacity.  Complete  ankylosis  of  the  hip  may  be  valued  at  as  much 
as  80  or  even  90  per  cent ;  at  an  angle,  58  per  cent ;  atrophy  of  muscle,  33  per 
cent.  If  fixed  in  the  flexed  position,  walking  and  standing  will  be  interfered 
with ;  and  if  the  fixation  is  in  the  extended  position,  there  may  be  a  difficulty 
in  sitting.  It  will  probably  take  at  least  eight  months  before  the  patient  is 
fit  to  begin  work  in  an  ordinary  simple  case  of  fracture  of  the  neck ;  this  is 
presuming  that  the  patient  is  not  beyond  middle  age,  and  that  there  are  no 
complications,   such  as  arthritis,   phlebitis,   pseudarthrosis,   etc. 

Fractures  of  the  Shaft  of  the  Femur  may  be  followed  by  non-union  and 
almost  complete  incapacity  for  work.  Union  with  shortening  and  deformity 
is  more  common.  In  measuring  the  shortening  it  is  well  not  to  forget  that  there 
is  sometimes  a  difference  in  the  length  of  normal  lower  limbs.  Some  authorities 
state  that  this  is  as  much  as  i  cm.,  and  the  increase  is  generally''  in  favour  of 
the  left  limb,  so  that  a  shortening  to  this  extent  may  be  considered  of  no  import- 
ance. OUive  and  le  Meignen  are  of  opinion  that  shortening  below  3  cm.  should 
not  be  compensated  unless  it  is  associated  with  other  lesions.  Brouardel 
reckons  great  shortening  to  be  that  above  5  cm.,  and  values  it  up  to  60  per  cent. 
In  the  lesser  degrees  of  shortening,  a  great  amount  of  accommodation  occurs, 
and  this  can  be  easily  assisted  by  adding  to  the  thickness  of  the  sole  of  the  boot. 

In  the  greater  degrees,  correction  is  difficult  and  the  incapacity  for  work  is 
considerable,  save  in  those  workers  who  can  sit  at  their  occupation.  The 
foregoing  remarks  on  shortening  apply  equally  to  fractures  of  the  tibia  and 
fibula. 

Angular  deformity  and  excessive  callus  formation  may  prevent  the  full  action 
of  muscles.  Pain  will  follow  the  involvement  of  nerves  in  callus,  and  it  is 
frequenth^  a  cause  of  incapacity  in  cases  of  union  with  overlapping  or  bowing 
of  the  limb  ;  standing  for  a  length  of  time  is  sometimes  impossible.  If  good 
alignment  of  the  fragments  is  achieved,  recovery  will  take  place  in  four  to  six 
months  ;    in  manj^  cases  it  will  be  as  much  as  twelve. 

Fractures  Involving  the  Knee  Joint  are  sometimes  followed  by  more  or  less 
ankylosis  or  weakness  in  the  joint.  If  the  ankylosis  is  in  the  straight  position, 
the  incapacity  is  about  40  per  cent ;  in  the  flexed  position,  according  to  degree, 
up  to  50  per  cent ;  relaxed  knee  joint,  58  per  cent.  The  insecurity  here  is 
most  noticed  in  going  up  or  down  ladders  or  stairs.  Marked  wasting  of  the 
muscles  of  the  thigh  frequently  follows  injuries  to  the  knee  joint.  In  simple 
cases  it  generally  takes  from  six  to  twelve  months  for  full  working  capacity  to 
be  restored. 

Fractures  of  the  Patella. — If  bony  union  is  achieved,  the  return  to  full  function 
is  the  usual  course.  If  the  union  is  fibrous  and  there  is  not  much  separation  of 
fragments,  a  useful,  though  not  perfect,  limb  results.  If  there  is  much  separation 
of  fragments,  a  weak  and  flail-like  limb  -wdll  result,  Avith  consequent  incapacity, 
which  may  be  as  much  as  50  per  cent. 

Fractures  of  the  Shafts  of  Tibia  and  Fibula,  united  with  deformity  or  with 
painful  callus,  are  often  associated  with  thrombosis,  swelling  of  the  limb,  and 
trophic  troubles.  If  non-union  occurs,  the  incapacity  is  great.  If  the  fracture 
is  in  the  upper  end,  involving  the  knee  joint,  the  resulting  condition  maj?^  approxi- 
mate that  found  in  fractures  of  the  femur  involving  the  knee  joint  (q.v.). 

If  the  fibula  is  fractured  near  the  upper  end,  the  peroneal  nerve  may  be  involved 
either  in  the  fracture  or  in  the  resulting  callus,  and  a  condition  of  talipes  equino- 
varus  ensue,  with  incapacity  for  work.  (For  shortening,  see  Fracture  of  the 
Femur.)  In  favourable  cases  a  worker  is  usually  fit  to  return  to  work  in  three 
or  four  months. 

Fractures  of  the  lower  end  of  tlie  tibia  and  fibula  involving  the  ankle  joint  are 


FRACTURES  191 


grave  injuries,  and  very  frequently  result  in  serious  incapacity.  Deformity,  a 
varying  degree  of  ankylosis,  and  pain  are  the  most  frequent  sequelae.  If  the 
foot  is  fixed  at  a  right  angle — the  most  favourable  position — the  incapacity  may 
be  from  15  to  20  per  cent,  according  to  the  nature  of  the  work.  If  fixed  at  an 
acute  angle,  or  in  an  extended  position,  the  incapacity  may  be  as  much  as  60 
per  cent.  The  older  the  patient,  the  less  is  the  chance  of  his  being  able  to  return 
to  full  work. 

The  opinion  of  the  late  Mr.  Clinton  Dent,  mentioned  earlier,  having  reference 
to  that  picked  body,  the  Metropolitan  Police,  shows  how  very  serious  these 
injuries  are  in  persons  whose  occupation  requires  long  standing  or  walking. 

Fractures  involving  the  Tarsus  and  Metatarsus  may  sometimes  cause  perma- 
nent incapacity,  occasionally  equal  to  loss  of  the  foot,  on  account  of  pain, 
swelling,  and  difficulty  in  walking,  or  standing  for  a  long  time.  Flat-foot  may 
ensue,  and  it  is  valued  at  from  30  to  50  per  cent.  Sometimes  the  strain  on  the 
sound  foot  occasioned  by  the  weight  of  the  body  being  thrown  on  it  in  an  effort 
to  save  the  injured  foot,  causes  a  condition  of  fiat-foot  in  a  previously  healthy 
foot. 

In  metatarsal  fractures,  if  there  is  much  displacement  of  the  fragments  either 
in  an  upward  or  downward  direction,  the  pressure  of  the  workman's  hard  boot 
may  cause  very  definite  incapacity  ;    metatarsalgia  may  ensue. 

Fractures  of  the  Toes  rarely  cause  incapacity  unless  they  become  compound 
and  septic.  The  loss  of  the  great  toe  is  estimated  at  from  10  to  20  per  cent. 
The  loss  of  a  single  phalanx  does  not  cause  any  incapacity  unless  the  scars 
are  tender.  The  loss  of  several  toes  or  all  the  toes  may  be  estimated  at  from 
20  to  30  per  cent  as  a  maximum.  In  many  tarsal  fractures  it  will  be  six  to 
eight  months  before  the  patient  is  fit  to  undertake  heavy  work,  or  metatarsal 
fractures  three  to  six  months. 

Fractures  about  the  Upper  End  of  the  Humerus  may  be  followed  by  more  or 
less  ankylosis,  and  consequent  limitation  of  movement,  atroph}'  of  muscles, 
injury  to  the  circumflex  nerve,  or  chronic  arthritis.  Ankylosis  may  be  estimated 
according  to  degree  at  from  50  to  60  per  cent ;  atrophy  of  muscles  28  to  58 
per  cent ;  chronic  arthritis  16  to  66  per  cent.  Arthritis  may  greatly  delay 
recovery.  Benign  cases  are  well  usually  in  two  to  four  months,  but  severe 
ones  may  last  as  much  as  twelve  months  or  more. 

Fractures  of  the  Shaft  of  the  Humerus  may  be  followed  by  non-union  (which 
is  relatively  frequent),  faulty  position,  pain,  and  involvement  of  the  musculo- 
spiral  nerve  in  callus.  Any  of  these  may  cause  almost  complete  incapacity. 
In  uncomplicated  cases  recovery  is  usually  complete  in  three  to  four  months. 

Fractures  at  the  Lower  End  of  the  Humerus  and  Elbow  Joint  may  be  followed 
by  complete  or  incomplete  ankylosis,  or  loss  of  movements  of  pronation  and 
.supination.  Ankylosis  in  extension  may  be  estimated  at  from  40  to  50  per  cent ; 
in  medium  flexion,  33  to  40  per  cent ;  in  acute  flexion,  20  to  25  per  cent.  Loss 
of  pronation  and  supination  may  be  a  serious  disability,  especially  in  skilled 
workers,  mechanics,  etc.  Simple  uncomplicated  cases  frequently  recover  full 
working  capacity  in  three  months. 

Fractures  of  the  Radius  and  Ulna  are  sometimes  followed  by  disability  due 
to  non-union  or  faulty  union.  In  non-union  the  forearm  is  practically  useless, 
and  in  faulty  union  there  is  frequently  loss  of  pronation  and  supination. 

Fractures  at  the  Lower  End  of  the  Radius  and  Ulna  involving  the  Wrist  Joint  are 
sometimes  followed  by  more  or  less  ankylosis.  Complete  ankylosis  of  the 
wrist  is  estimated  at  from  25  to  33  per  cent.  Partial  ankylosis  may  not  interfere 
with  working  capacity  except  in  specially  skilled  trades.  In  favourable  cases, 
probably  about  three  months  may  be  reckoned  as  the  period  of  recovery. 


192  INDEX     OF     PROGNOSIS 

Fractures  of  the  Carpus  may  cause  ankylosis  similar  to  that  which  follows 
fractures  in  the  wrist  joint.  Simple  cases  recover  in  from  one  to  three  months; 
the  lesser  period  will  apply  to  those  cases  in  which  movements  can  be  begun  early. 

Fractures  of  the  Metacarpus  are  not  usually  followed  by  any  very  great 
incapacity  unless  the  bones  are  united  with  great  displacement. 

Fractures  of  the  Phalanges  do  not  generally  cause  much  disability.  If  the 
finger  is  ankylosed  in  a  straight  or  flexed  position,  there  will  be  interference 
with  the  full  power  of  the  hand,  and  amputation  may  be  necessary  to  restore 
function.  Loss  of  the  thumb  is  the  most  important,  as  the  hand  is  a  forceps 
as  well  as  a  grasping  instrument. 

If  loss  of  a  hand  be  reckoned  at  from  50  to  75  per  cent,  loss  of  the  thumb 
will  be  equal  to  about  one-third  of  this. 

Ankylosis  of  thumb  joints,  25  to  33  per  cent ;  loss  of  a  single  phalanx  of  the 
thumb  is  a  serious  matter. 

Loss  of  index  finger,  16  to  25  per  cent. 

Ankylosis  of  index  joints,  8  to  25  per  cent ;  loss  of  one  or  more  phalanges 
of  the  index  will  equal  one-  to  two-thirds  of  the  total  loss  of  the  index. 

The  estimation  of  the  loss  of  the  middle  finger  is  about  8  to  16  per  cent,  and 
the  loss  of  the  ring  finger  is  a  little  less. 

The  loss  of  the  little  finger  is  valued  just  under  the  last  two  mentioned. 

Fractures  of  the  Scapula. — If  union  is  in  a  faulty  position,  so  as  to  interfere 
with  the  movements  of  the  shoulder  or  render  these  painful,  the  valuation  of 
the  incapacity  is  estimated  at  from  10  to  30  per  cent.  Most  lesions  about  the 
shoulder  are  followed  by  an  amount  of  wasting  of  muscle  which  frequently 
takes  quite  a  long  time  to  recover. 

Fractures  of  the  Sternum. — In  simple  uncomplicated  fractures  the  prognosis 
is  usually  good,  though  pain  is  sometimes  persistent,  but  rarely  wholly 
incapacitating.  If  the  ensiform  cartilage  is  driven  inwards,  an  operation  may 
be  required  to  raise  it.  Remy*^  suggests  10  to  20  per  cent  valuation  for  a  sinking 
in  of  the  sternum  without  deep  lesions. 

Fractures  of  the  Clavicle  usually  result  in  some  deformity;  but  if  uncompli- 
cated by  injury  to  adjacent  parts,  there  is  in  most  cases  an  excellent  recovery. 
Non-union  is  rare,  but  if  it  occurs  an  operation  will  be  necessary.  Excessive 
callus  formation  may  cause  pressure  symptoms,  pain,  and  incapacitj'-  for  work. 
The  estimation  for  imperfect  recovery  is  from  16  to  50  per  cent.  In  an  ordinary 
case,  about  two  months  will  elapse  before  full  work  can  be  undertaken.  In 
severe  cases  it  may  be  much  longer. 

Fracture  of  the  Ribs. — Uncomplicated  fractures  usually  heal  well,  and  there 
is  generally  very  little  incapacity  for  work  afterwards.  Sometimes  faulty 
union  and  excessive  callus  formation  may  leave  painful  neuralgia  as  a  result. 
If  incapacity  occurs  on  raising  the  arm,  or  is  due  to  pain,  it  may  be  reckoned 
at  from  20  to  50  per  cent,  or  even  more.  Austrian  statistics  record  141 5  cases 
of  fractured  ribs  ;  of  these,  806  have  completely  recovered  in  periods  up  to  seven 
months. 

Fractures  of  the  Pelvis, — Fractures  of  the  pelvis  are  frequently  complicated 
with  fatal  internal  injuries.  If  recovery  takes  place,  pain  may  be-  persistent, 
or  it  may  be  elicited  by  movements,  and  as  a  consequence  walking  may  be 
difficult.  Simple  fractures  of  the  ilium  may  unite  with  deformity,  causing 
very  little  incapacity  . 

Fractures  of  the  Sacrum  may  result  in  great  incapacity,  particularly  if  nerves 
are  involved. 

References. — ^ Lucas -Championniere,  Precis  du  TraUement  des  Fractures  par  le 
Massage  et  la  Mobilisation,  Paris,  1910 ;  ^Ewald,  Zenlr.  f.  Chir.  No.  14,  1914,  April  4  ; 


GALL-STONES  193 


^ClintoQ  Dent,  Clin.  Jour.  1908,  Oct.  7  ;  ^Dujarier,  Jour,  de  Chir.  1913,  Sept. ;  ^Pierre 
Fredet,  Jour,  de  Chir-  1913,  Sept.;  ®Fred.  H.  AXh&e,  Amer.  Jour.  Surg.  1914,  Jan.; 
"Siauve,"  De  Quelques  Fractures  Articulaires  et  J uxta-articiilaires  "  These  de  Lille,  1913  ; 
*Scudder,  The  Treatment  of  Fractures,  1905  ;  ^Walker  (New  York),  Ann.  Surg.  1908, 
June;  i^Ashhurst  and  Newell  (Philadelphia),  Ibid.  1908,  Nov.;  "John  B.  Walker, 
Ibid.  1912,  Dec;  ^^Helferich,  "Fractures  and  Dislocations,"  Sydenham  Soc.  1899; 
"Bull  (New  York),  Med.  Rec,  1890,  Mar.  22;  "Powers,  Ami.  Surg.  1898,  July; 
^^Stimson,  A  Practical  Treatise  on  Fractures  and  Dislocations,  1910  ;  ^*Lockwood, 
Brit.  Med.  Jour.  1911,  Junes;  ^'H.  Beeckman  Delatour,  Ann.  Surg.  1914,  June; 
i^Comer,  Ann.  Surg.  1910,  Nov.  ;  ^'Hitzrot,  Ibid.  1912,  Mar.;  ^^Chaput,  Les  Fractures 
Malleolaires  du  Cotc-de-Pied,  Paris ;  ^^G.  Gayet,  Lyon  Chir.  1909,  June ;  --Cabot 
and  Binney,  Ibid.  ;  ^Leonard  W.  Ely,  Ann.  Surg.  1907,  Jan.;  -^Macausland  and  Wood, 
Ibid.  1910,  Dec.  ;  ^^Abadie  et  Range,  Rev.  de  Chir.  1910,  Sept.  ;  ^^Scudder  and  Paul, 
Ann.  Surg.  1909,  Dec.  ;  ^'Andre  Treves,  Etude  stir  les  Fractures  de  I'Extremite 
Inferieure  de  V Humerus  chez  V Enfant,  Paris,  191 1  ;  ^^Poland,  "Traumatic  Separation 
of  Epiphyses";  ^Cotton,  Dislocations  and  Fractures,  1910 ;  ^''Lambotte,  Chirurgie 
Operatoire  des  Fractures,  1913  ;  ^^W.  A.  Campbell,  Lancet,  1912,  ii,  1296  ;  •'^Ebermaj'er, 
"  Fortschr.  a.  d.  Geb.  Roentgenstrahlen,"  1908  ;  ^^Finisterer,  Zentr.  f.  Chir.  1908  ; 
3*A.  H.  Harrigan,  Ann.  Surg.  1908,  Dec.  ;  ^*W.  P.  Coues,  Ibid.  1912,  Sept.  ;  ^^Preiser, 
Miinch.  med.  Woch.  1907;  ^'Paul,  Ibid.  1901,  June;  **Brouardel,  Les  Accidents  du 
Travail ;  ^^Rohmer,  UEvaluation  des  Incapacifes  Professionelles  ;  ^^Ollive  et  Le 
Meignen,  Les  Accidents  du  Tra,vail ;  "Remy,  UEvaluation  des  Incapacites  Permanenfes. 

W.  J.  Greer. 
FRIEDREICH'S  ATAXIA.— (5ee  Ataxia.) 

FRONTAL  SINUSITIS. — [See  Nasal  Accessory  Sinusitis.) 

GALL-STONES. — We  shall  inquire  [A)  Into  the  prospect  0/  severe  trouble 
arising  from  the  presence  of  gall-stones;  and  (-B)  Concerning  the  risks  and 
benefits  of  the  various  forms  of  operation. 

A.  The  Prognosis  of  Gall-stones  apart  from  Operation. — As  is  well  known, 
gall-stones  are  very  frequently  found  at  the  autopsy  in  cases  where  their 
presence  was  never  suspected  during  life.  They  are  said  to  be  present  in  4  per 
cent  of  all  adult  males  and  20  per  cent  of  all  adult  females,  and  are  undoubtedly 
commoner  in  the  obese.  Only  in  about  one-fifth  of  the  cases  are  typical  attacks 
of  gall-stone  colic  recognized. 

As  Moynihan  has  forcibly  pointed  out,  this  does  not  mean  that  the  remaining 
four-fifths  never  have  any  symptoms.  A  large  proportion  of  them  have  uneasy 
sensations  of  fullness,  which  may  amount  to  agonizing  attacks  of  pain,  not  in 
the  right  hypochondrium  but  in  the  stomach.  It  is  not  at  all  uncommon  for 
a  very  exact  mimicry  of  gastric  ulcer  to  be  the  result,  and  it  may  even  be  supposed 
from  the  severity  of  the  symptoms  that  the  ulcer  has  perforated.  In  a  number 
of  these  cases  hyperchlorhydria  is  found,  and  some  of  them  do  actually  develop 
a  gastric  ulcer  in  consequence. 

Gall-stone  coh'c  with  or  without  jaundice,  and  gastric  symptoms,  are  there- 
fore quite  common  evidences  of  the  presence  of  calculi  in  the  gall-bladder. 
There  are  a  number  of  less  frequent  ill-effects.  In  about  20  per  cent  of  the 
cases  which  are  sufficiently  severe  to  come  into  hospital  for  operation,  a  stone 
becomes  impacted  in  the  common  bile-duct,  and  in  a  further  10  per  cent  in 
the  cystic  duct  (Kehr,  Mayos,  the  Bristol  figures).  Stone  in  the  common  duct 
causes  persistent  jaundice  and  pain,  and  sometimes  febrile  attacks  ;  stone  in 
the  cystic  duct  gives  rise  to  dilatation  of  the  gall-bladder,  either  simple  (muco- 
cele) or  infected  (empyema  of  the  gall-bladder). 

Another  trouble  resulting  from  gaU-stones  may  be  a  fistulous  opening  into 
the  peritoneal  cavity,  some  viscus,  or  on  the  skin  surface.  In  Courvoisier's 
statistics  collected  from  the  literature,  there  were  184  cases  of  cutaneous  fistula 
(usually  at  the  umbilicus),  119  of  perforation  into  the  peritoneal  cavity,  83 
into  the  duodenum,  39  into  the  colon,  24  into  the  lung,  and  a  very  few  each 


194 


INDEX     OF     PROGNOSIS 


into  the  stomach,  kidney,  and  ureter.  In  4  cases  (one  of  whom  was  Ignatius 
Loyola)  the  inferior  vena  cava  was  opened  by  a  gall-stone  fistula. 

Acute  cholecystitis  is  a  quite  common  consequence  of  stones  in  the  gall- 
bladder, and  occasionally  leads  to  perforation  and  peritonitis.  Subphrenic 
abscess  or  abscess  of  the  liver  may  also  result. 

Intestinal  obstruction  due  to  gall-stones  is  rare,  but  many  hundreds  of  cases 
are  on  record.  Of  280  in  the  literature,  156  died  (Martin),  but  literature 
statistics  are  seldom  very  valuable.  Occasionally,  adhesions  around  the  bile- 
passages  may  lead  to  intestinal  obstruction. 

Cancer  of  the  bile-ducts  or  gall-bladder  is  a  well-recognized  consequence  of 
the  long-continued  irritation  of  calcuU.  We  have  some  figures  giving  us  an 
idea  of  the  frequency  of  this  result.  Cancer  was  present  in  18  out  of  409  cases 
at  the  London  Hospital,  and  45  out  of  333  cases  at  Guy's.  The  greater  fre- 
quency is  due  to  the  older  date  of  the  statistics  ;  nowadays  many  more  cases 
are  operated  on  early.  Combining  these  figures,  we  obtain  a  frequency  of 
8  per  cent ;  the  ancient  statistics  of  Riedel  were  as  high  as  28  per  cent.  It 
will  be  seen,  however,  that  the  danger  of  cancer  is  by  no  means  negligible  if 
even  8  per  cent  of  patients  with  symptoms  sufficiently  severe  to  be  operated 
upon  already  show  it.  Walton  records  3,  and  Mayo  Robson  and  Lawford 
Knaggs  I  each,  cases  in  which  cancer  has  supervened  after  operation,  but  this 
is  evidently  extremely  rare.  In  the  end-result  statistics  of  Kehr,  Davis, 
Arnsperger,  McWilliams,  Stanton,  and  the  Bristol  figures,  comprising  nearly 
a  thousand  in  all,  this  sequel  is  not  once  mentioned. 

We  conclude,  therefore,  that  in  the  majority  of  cases  the  presence  of  gall- 
stones leads  to  some  discomfort,  which  in  about  one-fifth  of  the  cases  is  very 
severe,  though  it  may  be  only  temporary  ;  that  of  those  who  show  marked 
signs  about  one-third  eventually  suffer  from  impaction  of  a  gall-stone,  or  develop 
a  fistula  or  acute  cholecystitis  demanding  prompt  interference  ;  that  another 
8  per  cent  go  on  to  cancer  of  the  bile-passages,  and  that  a  small  proportion, 
perhaps  i  per  cent,  lose  their  hves  from  intestinal  obstruction,  perforative 
peritonitis,  or  subphrenic  abscess. 

It  is  scarcely  reaUzed  by  the  profession  that  the  prognosis  of  gall-stones, 
apart  from  treatment,  is  as  grave  as  these  facts  prove.  It  will  probably  be 
admitted  by  nearly  everyone  that  the  prospects  of  permanent  relief  of  symptoms 
by  medical  treatment — olive  oil,  salines,  mineral  waters  and  spa  treatment, 
dieting,  etc. — are  very  slight,  and  any  patient  who  has  had  one  attack  of 
hepatic  colic  will  most  probably  get  others.  Fortunately  these  are  often  at 
long  intervals,  so  that  life  may  be  tolerable  notwithstanding. 

B.  The  Prognosis  of  Operation  for  Gall-stones. — We  shall  consider,  first,  the 
operation  mortality  and  its  causes,  and  then  the  prospects  of  permanent  cure. 

Table  I. — The  Operation  Mortality  for  Gall-stones. 


All  cases 

stones  in 
GaU- bladder 

Duct  cases 

Serious 
complications 

No. 

Died 

No. 

Died 

No. 

Died 

No. 

Died 

D'Arcy  Power 

Kehr      .... 

Mayo      .... 

Bristol  Royal  Infirmary 

Arnsperger      - 

Munro    -         -        .        - 

73 
1600 
1500 

84 
230 
200 

per  cent 

23-3 
16-5 

4-4 
13 

6 -9 

0 

53 

691 

1164 

31 

per  cent 

n-3 

2-9 
2-5 
9-6 

389 
105 

27 

per  cent 

3-3 

2-9 
11 

20 
520 
102 

12 

percent 
55 
44-6 
24 
42 

GALL-STONES 


195 


I.  Operation  Mortality. — As  a  glance  at  Table  I  will  show,  it  is  impossible 
to  give  a  figure  for  the  death-rate  of  the  operation  for  gall-stones  which  will 
not  be  utterly  misleading  if  applied  to  particular  cases  without  discrimination. 
Everything  depends  on  the  exact  nature  of  the  individual's  condition. 

In  absolutely  straightforward,  uncomplicated  cases,  the  mortality  is  very 
low.  D'Arcy  Power  records  27  such  without  a  death  ;  Kehr  collects  statistics 
of  2494  operations  of  this  type  with  a  mortality  of  3-6  per  cent.  On  the  other 
hand,  in  the  presence  of  '  serious  complications,'  including  cancer,  peritonitis, 
infection  with  fever  or  pus,  gastric  ulcer,  etc.,  most  of  the  statistics  range  about 
50  per  cent. 

In  Table  I  we  are  able  to  give  in  some  detail  four  series  of  recent  figures. 
D'Arcy  Power  quotes  73  cases  under  his  observation  in  St.  Bartholomew's 
Hospital  from  1900  to  1912.  The  total  mortality  is  high  (23-3  per  cent),  because 
in  England  it  is  principally  the  severe  or  complicated  cases  that  are  sent  to  a 
hospital.  He  does  not  distinguish  between  stones  in  the  gall-bladder  and  in 
the  ducts.  The  Bristol  Royal  Infirmary  figures,  representing  the  practice 
of  nine  surgeons  during  the  years  1900-1911,  are  very  similar,  but  present  a 
smaller  proportion  of  serious  complications,  so  that  the  total  death-rate  is 
much  less.  It  will  be  observed  that  even  in  the  absence  of  such  serious  comph- 
cations,  about  i  in  10  die. 

Kehr,  of  Halberstadt,  who  performs  an  enormous  number  of  operations 
for  gall-stones,  can  quote  1600  cases,  his  total  death-rate  being  rather  higher 
than  that  in  the  Bristol  series,  but  in  uncomplicated  cases  his  results  are  much 
better,  the  mortality  being  2-9  percent  when  the  stones  are  in  the  gall-bladder 
and  3-3  per  cent  if  in  the  ducts.     The  statistics  run  over  twenty  years. 

The  Mayos  also  record  a  long  series,  and  they  appear  to  deal  with  a  much 
simpler  type  of  case  than  the  English  or  German  material,  so  their  total  death- 
rate  is  only  4-4  per  cent.  Their  figures  in  uncomplicated  cases  are  a  little 
better  than  Kehr's,  and  much  better  than  the  English.  There  is  little  doubt 
that  when  it  becomes  the  rule  to  call  in  the  surgeon  early  instead  of  late,  the 
death-rate  will  fall  considerably.  In  the  Bristol  figures,  for  instance,  it  was 
very  remarkable  to  observe  how  the  formation  of  adhesions  affected  the  prognosis. 
Of  19  cases  with  extensive  adhesions,  30  per  cent  died. 

In  all  the  figures,  the  common-duct  cases  show  a  mortality  rather  higher 
than  those  with  stones  in  the  gall-bladder  only.  Cholecystectomy  is  more 
severe  than  cholecystotomy  ;    thus  : — 


Cholecystotomy 
Cholecystectomy 


Mayo 


845  cases;    2-1%  died 
319  cases;    31%  died 


Kehr 


307  cases;    2-2%  died 
384  cases ;   3-3%  died 


The  additional  risk  is  due,  not  so  much  to  the  added  severity  of  the  operation, 
as  to  the  fact  that  the  necessity  for  removal  shows  a  more  complicated  type  of 
case,  at  any  rate  in  the  hands  of  the  above-mentioned  surgeons.  Of  12  cases 
of  stone  impacted  in  the  cystic  duct  in  the  Bristol  series,  none  died. 

The  causes  of  death  are  illustrated  by  the  Bristol  statistics  :  shock,  3  cases  ; 
peritonitis,  3  ;  gastric  ulcer,  2  ;  fatty  heart  (twenty-one  days  after),  i  ;  pneu- 
monia, I  ;  cut  portal  vein,  i  ;  intestinal  obstruction,  i.  Cancer  also  accounts 
for  some  fatal  results.  A  few  jaundiced  patients  die  of  persistent  haemorrhage. 
Some  writers  describe  a  post-operative  cessation  of  the  hepatic  functions, 
characterized  by  absence  of  bile,  fever,  vomiting,  and  death.     Both  Kehr  and 


196 


INDEX     OF    PROGNOSIS 


D'Arcy  Power  remark  that  the  death-rate  is  much  higher  in  males  than  females, 
being  approximately  double. 

2.  The  Prospects  of  Cure.- — We  have  available  several  series  of  end-results 
of  cases  followed  for  periods  varjdng  from  one  to  ten  years  after  operation,  and 
representing  English,  German,  and  American  practice.  Kehr  and  Davis  also 
give  figures,  but  the  first  are  not  followed  long  enough  and  the  second  are 
too  vaguely  expressed.  In  the  table,  aU  forms  of  operation  for  gall-stones  are 
classed  together. 

Table    II. — Prospects  of  Relief  after  Operation  for  Gall-stones. 


Author 

Number 
traced 

Cured 

Better 

Unrelieved 

Incisional 
Hernia 

Second 
Operation 

per  cent 

per  cent 

per  cent 

per  cent 

per  cent 

Arnsperger      -         -         -         - 

147 

64-6 

19-7 

6-9 

8-8 

9 

McWUliams    -         -         -         - 

68 

66-2 

10 

23 

9 

18 

Stanton           -    .      - 

245 

79 

15 

6 

3 

2 

D'Arcy   Power 

20 

70 

— 

20 

10 

0 

Bristol   Roj^al   Infirmary 

59 

52-5 

32-2 

15-2 

5 

6-7 

Arnsperger  records  the  cases  operated  on  at  Heidelberg  in  the  years  1907- 
1909,  it  being  customary  to  remove  the  gall-bladder.  Both  he  and  Davis 
specially  warn  against  stitching  the  gall-bladder  to  the  abdominal  wall.  It  will 
be  seen  that  about  two-thirds  of  the  patients  were  cured  and  only  6-9  per  cent 
were  unreKeved.  McWilliams's  figures  are  rather  older  (pubhshed  in  1906), 
and  there  is  a  high  proportion  of  cases  not  benefited,  or  requiring  a  second  opera- 
tion. Stanton  gives  the  end-results  from  Ochsner's  chnic,  where  the  results 
are  much  better,  perhaps  on  account  of  earlier  operation.  D'Arcy  Power's 
cases  are  few  in  number,  and  many  of  them  were  operated  on  late  in  the  disease. 
The  Bristol  figures  are  from  the  same  series  as  was  quoted  under  the  heading 
of  mortahty,  and  show  only  about  half  cured,  but  another  third  improved  ; 
perhaps  the  difference  between  this  and  the  other  reports  is  principally  in  the 
use  of  the  word  '  cured,'  which  in  the  Bristol  table  is  taken  to  mean  absolute 
freedom  from  symptoms. 

Taking  all  together,  we  may  conclude  that  about  85  per  cent  are  cured  or 
relieved  by  operation,  and  the  remainder,  about  15  per  cent,  are  not  improved. 
What  are  the  causes  of  lack  of  success  ?  PrincipaUy  three  :  (a)  Recurrence  of 
the  stones  ;  (&)  Adhesions  ;  and  (c)  Incisional  hernia.  Second  operations  have 
often  been  performed,  so  that  we  are  informed  as  to  the  relative  frequency  of 
these.     Thus  : — 


Arnsperger —  gall-stones,  11  cases; 

McWUliams —  „  8        „ 

Stanton —  ,,  8        ,, 

Bristol  Roval  Infirmary —    ,,  1        ,, 


adhesions,  13    cases. 
4 
10 


Adhesions,  therefore,  are  rather  commoner.  It  is  very  difficult  to  say  whether 
the  gall-stones  are  new  formations,  or  stones  overlooked  and  perhaps  increased 
in  size  since  the  first  operation  ;  probably  the  latter  is  more  usual.  Adhesions 
may  produce  symptoms  exactly  like  hepatic  cohc.  Second  operations  in  this 
class  are  not  often  successful. 

It  is  noteworthy  that  there  is  sometimes  an  attack  of  severe  pain  and  jaundice 
soon  after  the  operation,  which  therefore  appears  to  have  failed,  followed  by 
permanent  cure.  This  is  mentioned  by  Munro,  and  was  seen  in  three  Bristol 
cases.     It  is  probably  due  to  catarrh  of  the  ducts. 


GANGRENE  197 

Removal  of  the  gall-bladder  is  not  a  certain  preventive  of  re-formation  of 
calculi ;  Arnsperger  relates  three  cases  in  which  they  recurred  in  the  common 
duct.  Incisional  hernia  is  quite  a  common  sequel,  figures  varying  from  3  to 
10  per  cent.     It  often  gives  but  little  trouble. 

There  is  not  much  difference  in  the  end-results  whether  the  stones  were  in 
the  gall-bladder,  cystic  duct,  or  common  bile-duct.  In  Stanton's  series,  the 
common-duct  cases  gave  the  most  failures,  whereas  in  the  Bristol  series  there 
were  very  few  of  these  who  did  not  get  relief.  The  principal  factor  in  deter- 
mining the  end-result  is  the  amount  and  density  of  adhesions  found.  In  the 
Bristol  cases  with  extensive  adhesions,  6  out  of  19  died  and  36  per  cent  were 
unrelieved,  whereas  in  the  absence  of  adhesions  only  10  per  cent  failed  to  obtain 
benefit.  Stanton  reports  that  of  107  uncomplicated  cases  of  stones  in  the 
gall-bladder,  only  5-4  per  cent  were  unsatisfactory. 

We  conclude,  therefore,  that  in  simple,  early  cases  the  mortality  of  operation 
is  about  3  per  cent,  and  that  90  to  95  per  cent  will  be  greatly  benefited  ;  that 
in  the  type  of  case  usually  operated  on  in  England  after  months  or  years  of 
recurrent  gall-stone  colic,  10  per  cent  die  and  about  85  per  cent  of  the  survivors 
are  relieved  ;  and  that  in  cases  with  serious  complications  such  as  infection, 
perforation,  cancer,  etc.,  about  50  per  cent  die,  and  relief  is  likely  to  be  incom- 
plete in  most  of  the  patients.  It  is  evident,  therefore,  that  to  obtain  the  best 
results  from  the  operation  for  gall-stones,  it  ought  to  be  undertaken  decidedly 
earlier  than  is  now  the  custom.  For  this  reason,  the  figures  of  a  few  enterprising 
American  surgeons  are  better  than  those  of  average  English  practice. 

References. — Arnsperger,  Milnch.  med.  Woch.  1912,  lix,  6  ;  Davis,  Surg.  Gyn.  and 
Obst.  1912,  XV,  27  ;  Kehr,  Milnch.  med.  Woch.  1910,  s.  1986  ;  Kehr,  Deuxiime 
Congres  de  la  Soc.  Internal,  de  Chir.  Rapp.,  1908,  ii,  422  ;  Mayo,  Ann.  Surg,  xliv, 
1906,  209  ;  McWilliams,  N.Y.  Med.  Jour.  1906,  Ixxxiii,  1109  ;  Munro,  Boslon  Med.  and 
Surg.  Jour.  1909,  clx,  359  ;  D'Arcy  Power,  Brit.  Jour.  Surg.  1913,  July,  21  ;  Rendle 
Short,  Bristol  Med.-Chir.  Jour.  1913,  34;  Stanton,  Jour.  Amer.  Med.  Assoc.  1911,  Ivii, 
441  ;    Walton,  Ann.  Surg,  liv,  1911,  199.  a.  Rendle  Short. 

GANGRENE. — The  prognosis  of  this  disease  depends,  of  course,  upon  the 
cause  of  the  gangrene.  That  due  to  malignant  oedema  is  dealt  with  elsewhere 
{see  CEdema,  Malignant).  Gangrene  due  to  Raynaud's  disease  is  likely  to  lead 
to  loss  of  the  finger-tips,  but  there  is  no  danger  to  life.  When  due  to  frost-bite, 
to  embolism  of  a  main  artery,  or  to  injury,  it  will,  of  course,  necessitate  amputa- 
tion ;  but  there  is  no  great  danger  of  the  gangrene  spreading,  or  of  life  being 
imperilled  unless,  owing  to  delay,  septic  infection  from  the  dead  area  takes  place. 

We  shall  particularly  consider  here  the  outlook  in  cases  of  senile  and 
diabetic  gangrene  :  (i)  In  relation  to  the  limb  ;  (2)  In  relation  to  the  life  of 
the  patient  ;    and  (3)  In  relation  to  the  treatment. 

I.  Prognosis  as  to  the  Limb. — It  is  often  difficult  to  be  sure  exactly  how  much 
of  a  limb  is  irretrievably  affected.  Sometimes  the  skin  turns  black,  but  the 
deeper  structures  are  living.  When,  however,  the  duskiness  appears  to  be 
deep-seated,  and  the  region,  usually  the  foot,  is  painful  or  no  longer  sensitive  to 
pressure,  it  is  beyond  recovery.  If  a  line  of  demarcation  forms,  it  is  no  use  to 
expect,  in  senile  or  diabetic  cases,  that  this  will  be  the  limit  of  the  advance  of 
the  gangrene  ;  though  in  traumatic  or  embolic  gangrene,  or  in  cases  of  frost-bite, 
where  the  artery  is  blocked  at  a  particular  point,  the  disease  does  not  usually 
spread  above  a  line  of  demarcation.  In  senile  cases,  one  only  too  often  sees, 
after  a  while,  a  spreading  duskiness  even  above  the  line,  and  the  process  gradually 
advances  up  the  leg  if  it  is  allowed  to  do  so.  The  writer  recollects  seeing  in  a 
■workhouse  an  old  pauper  who  developed  gangrene  of  the  toe,  which  extended, 
in  the  course  of  years,  up  the  leg  to  the  middle  third  of  the  thigh  ;   but  for  seven 


INDEX    OF    PROGNOSIS 


years  he  persistently  refused  amputation,  and  still  retained  possession  of  his  dry, 
black,  stinking  leg  !  Such  a  case  is  unusual ;  most  patients  would  have  died 
of  septic  intoxication  long  before. 

In  many  cases  it  is  possible  to  foretell  how  much  of  a  limb  is  in  danger  by 
feeling  how  far  down  the  arteries  can  be  found  pulsating,  and  by  taking  a 
skiagram  to  see  how  far  up  the  vessels  the  calcareous  changes  extend. 

2.  Prognosis  as  to  Life. — This  is  usually  grave  in  an  untreated  case,  and  depends 
upon  the  rapidity  of  advance  of  the  gangrene,  the  age  and  condition  of  the 
patient,  and  the  degree  of  septic  absorption.  Much  sugar  in  the  urine  makes 
the  outlook  more  ominous,  and  if  there  is  a  good  deal  of  fever,  and  the  dead 
area  is  moist,  nothing  but  early  amputation  is  likely  to  save  the  patient's  life. 

3.  Prognosis  as  influenced  by  Treatment. — ^It  is  quite  useless,  in  a  senile  or 
diabetic  case,  to  amputate  at  the  site  of  any  line  of  demarcation  that  may  have 
formed.  Nor  has  the  operation  of  raaking  an  anastomosis  between  the  femoral 
artery  and  vein  met  with  success,  save  in  a  very  few  exceptional  cases.  The 
treatment  remaining,  therefore,  is  to  amputate  through  the  lower  third  of  the 
thigh ;  or,  in  early  cases  with  pervious  arteries,  at  the  site  of  election.  The 
amputation  conducted  under  such  circumstances  is  by  no  means  a  trifling  risk. 
Of  39  cases  so  treated  at  two  London  hospitals,  the  Middlesex  and  St.  Thomas's, 
from  1907  to  1911,  16  died  shortly  afterwards,  a  mortality  of  41  per  cent. 

A.  Rendle  Short. 
GASTRIC  ULCER. — {See  Stomach,  Medical  and  Surgical  Diseases  of.) 

GASTRITIS. — [See  Stomach,  Medical  Affections  of.) 

GENERAL  PARALYSIS  OF  THE  INSANE.— (5ee  Mental  Diseases.) 

GENU  VALGUM. — In  young  children  with  rickety  deformities,  this  condition 
may  improve  in  the  course  of  years,  with  splints  and  a  more  suitable  dietary  ; 
but  in  older  children  and  young  adults  the  deviation  of  the  knees  is  hkely  to  be 
permanent,  and  may  increase  up  to  the  age  at  which  growth  ceases.  The 
success  of  treatment  depends  much  on  the  technical  skill  of  the  individual 
surgeon,  but  it  is  usually  possible  to  obtain  an  excellent  result  at  a  smaU  risk  by 
the  Macewen  operation,  or  by  taking  a  wedge  out  of  the  tibia. 

A.  Rendle  Short. 

GENU    VARUM.— (5ee  Rickets.) 

GLANDERS. 

Acute  Glanders. — This  is  an  extremely  fatal  disease  ;  the  mortality  is  over 
90  per  cent.  Death  occurs  in  from  one  to  three  weeks.  Only  if  the  lesion  is 
localized  and  no  internal  organ  is  affected  can  a  favourable  termination  be 
hoped  for.     The  appearance  of  a  pustular  eruption  is  highly  ominous. 

Chronic  Glanders. — Half  of  these  cases  are  fatal.  In  this  form,  also,  so  long 
as  the  disease  is  localized  and  the  internal  organs  are  not  attacked,  recovery  may 
result.  But  the  course  of  the  disease  is  always  tedious,  and  tlie  patient  is  always 
subject  to  the  risk  of  the  occurrence  of  an  acute  attack.  e.  W.  Goodall. 

GLYCOSURIA. — {See  Diabetes  Mellitus.) 

GOITRE. — Swellings  of  the  thyroid  gland  may  be  due  to  a  variety  of  causes, 
of  which  the  following  are  the  most  important :  (i)  Parenchymatous  goitre  : 
(2)  Adenomatous  and  Cystic  goitre;  (3)  Papuliferous  goitre;  (4)  Malignant 
goitre  ;     (5)   Exophthalmic  goitre. 


GOITRE 


199 


1.  Parenchymatous  Goitre  usually  attacks  older  children  or  young  adults, 
advances  to  a  certain  extent,  and  then  becomes  stationary  for  the  rest  of  the 
patient's  life.  Not  uncommonly,  however,  it  may  resume  growth  and  produce 
marked  pressure  symptoms,  even  in  adults.  Sometimes  a  goitre  appears  rapidly 
and  increases  at  a  great  rate,  causing  considerable  dyspnoea. 

2.  Adenomatous  and  Cystic  Goitre  do  not  usually  show  the  same  tendency  to 
arrest,  but  very  gradually  increase  in  size.  Htemorrhage  into  a  cyst  may  bring 
on  urgent  dyspnoea. 

The  prognosis  as  regards  life  in  these  three  conditions  is  almost  always  favour- 
able. Suffocation  from  pressure  on  the  trachea  only  in  quite  rare  cases  comes 
on  so  rapidly  as  to  be  dangerous.  Apart  from  operation,  of  course,  some  patients 
would  pass  gradually  into  a  very  grave  condition  from  lateral  compression  of 
the  air-passages.  A  few  simple  goitres  in  elderly  persons  assume  malignant 
characters. 

Spontaneous  cure  is  not  to  be  hoped  for,  except  in  quite  recent  cases  in  young 
adults  or  children.  Iodides  or  thyroid  extract  will  aid  in  bringing  this  about, 
but  if  the  swelling  has  persisted  many  months  they  usually  fail.  It  is  often 
desirable  to  change  the  drinking-water  supply. 

In  rare  cases  of  goitre  the  internal  secretion  of  the  thyroid  becomes  deficient, 
and  myxoedema  ensues.  More  commonly  it  is  excessive,  with  mild  symptoms 
of  Graves's  disease. 

The  children  of  goitrous  mothers  suffering  from  deficient  thjn-oid  secretion 
are  apt  to  be  goitrous.  Congenital  swelling  of  the  thyroid  is  almost  invariably 
associated  with  goitre  in  the  mother,  and  the  child  may  be  a  cretin.  In  the 
great  majority  of  cases  of  goitre  in  women  there  is  no  thyroid  insufficiency, 
and  the  children  are  therefore  normal. 

The  prognosis  after  treatment  by  operation  is  very  favourable.  Only  a 
small  proportion  of  cases  of  goitre  need  be  operated  on,  marked  deformity  or 
dyspnoea  being  the  principal  indications,  and  "  there  is  never  too  much 
dyspnoea  "  for  the  operation  to  be  done  (Berry). 

The  operation  mortality  is  very  low.  At  the  Bristol  Royal  Infirmary  during 
the  paist  three  and  a  half  years,  59  operations  have  been  done  without  a  death. 
Kocher's  mortality  is  3  in  1000.  Of  267  innocent  cases.  Berry  lost  3,  2  dying 
of  heart  failure  and  i  of  pleurisy  following  a  wound  of  the  larynx.  A  general 
anaesthetic,  usually  open  ether,  was  used.  None  of  his  cases  developed  tetany 
or  myxoedema,  which  in  the  early  days,  when  all  or  nearly  all  the  thyroid  gland 
was  removed,  were  both  fairly  frequent.  Tetany  is  not  entirely  banished, 
however,  as  a  number  of  modern  operators  have  been  less  fortunate  than  Mr. 
Berry,  and  can  report  a  case  or  two.  It  appears  to  be  due  to  removal  of  the 
principal  functioning  parathyroid  glands  lying  behind  the  thyroid.  It  is  not 
usually  very  serious,  even  if  it  does  occur. 

The  end-results,  provided  an  adequate  removal  is  made,  are  most  satisfactory. 
In  Mr.  Berry's  tables,  222  out  of  274  are  perfectly  cured  as  far  as  the  goitre  is 
concerned  (traced  from  one  to  five  years,  very  few  less  than  one  year).  In 
two  cases  the  growth,  though  innocent,  is  extending,  and  in  one  stridor  persists. 
The  others  are  either  lost  sight  of,  or  some  swelling  remains. 

3.  Papilliferous  Goitre  is  by  no  means  so  favourable  in  its  prognosis.  It  is 
not  a  malignant  growth,  but  there  is  a  considerable  tendency  to  recurrence. 
Five  patients  came  under  Mr.  Berry's  care ;  i  is  lost  sight  of,  and  2  were  cured, 
but  in  2  others  the  growth  continued  enlarging  and  they  returned  for  operation 
after  operation  for  several  years. 

4.  Malignant  Goitre  is  uncommon,  and  the  prognosis  is  very  grave  indeed,  both 
as  regards  the  immediate  and  the  ultimate  results.     It  invades  the  larynx  and 


INDEX     OF    PROGNOSIS 


its  nerves  early,  and  causes  secondary  glands  in  the  neck.  Of  7  cases  in  Mr. 
Berry's  statistics,  3  died  after  the  operation,  i  is  lost  sight  of,  and  the  other  3 
died  of  recurrence  twelve,  fourteen,  and  sixteen  months  later. 

5.  Exophthalmic  Goitre. — This  is  discussed  elsewhere  (see  Exophthalmic 
Goitre). 

Referexce. — Berry,  Proc.  Roy.  Soc.  Med.  {Surg.  Sect.),  1908,  i,  pt.3,  21. 

A.  Rendle  Short. 

GONORRHCEA. — The  principal  object  in  the  treatment  of  gonorrhoea  is  to 
prevent  the  spread  of  the  infection  to  the  posterior  urethra,  since  there  is  no 
prospect  of  serious  complications  if  the  disease  is  confined  to  the  anterior  part 
of  the  urethral  mucous  membrane.  Formerly  it  was  recommended  that  local 
treatment  should  be  postponed  until  the  subsidence  of  the  acute  stage — a  most 
pernicious  doctrine,  as  the  gonococcus  was  thereby  enabled  to  make  its  progress 
unchecked  into  the  posterior  part  of  the  urethra. 

If  the  patient  is  seen  in  the  incipient  stage  of  the  disease,  attempts  may  be 
made  to  abort  it,  and  to  destroy  the  gonococcus  before  it  has  had  time  to  spread 
far  down  the  urethra.  This  is  best  effected  in  the  following  manner.  The  anterior 
urethra  is  first  cocainized  by  a  solution  of  cocaine  and  adrenalin,  and  a  urethro- 
scopic  tube  subsequently  introduced  to  its  full  extent ;  down  this  tube  a  pledget 
of  cotton-wool  saturated  with  a  solution  of  nitrate  of  silver  10  gr.  to  i  oz.  should 
be  introduced  on  a  holder,  and  the  whole  of  the  anterior  urethra  thoroughly 
swabbed  out.  The  reaction  may  be  severe,  but  it  usually  subsides  in  a  short 
time,  leaving  a  watery  discharge  which  clears  up  in  three  or  four  days.  But  it  is 
seldom  that  the  disease  can  thus  be  attacked  in  its  early  stages,  and  when  once 
the  prostatic  urethra  has  been  invaded  by  the  gonococcus,  the  patient  is  liable  to 
complications,  and  a  guarded  prognosis  must  be  given. 

When  the  whole  urethra  is  infected,  treatment  by  irrigation  or  injections  must 
be  adopted  ;  the  modifications  of  nitrate  of  silver,  such  as  protargol,  argyrol, 
argaldin,  or  ichthargan,  have  a  destructive  effect  on  the  gonococcus,  and  should 
be  employed  as  long  as  that  organism  is  present  in  the  discharge  ;  astringent 
injections,  such  as  sulphate,  permanganate,  or  sulphocarbolate  of  zinc,  may  be 
used  alternately  with  the  silver  salts  ;  at  the  same  time  a  rigid  abstinence  from 
alcoholic  liquors  should  be  enforced,  and  no  violent  exercise  should  be  taken. 
A  long  continuance  of  the  discharge  or  frequent  infections  may  give  rise  to  peri- 
urethral thickening,  which  contracting  forms  a  stricture,  the  dilatation  of  which 
will  often  be  followed  by  a  cessation  of  the  discharge. 

If  the  posterior  urethra  is  attacked,  the  complications  to  which  the  patient  is 
liable  are  more  numerous  and  more  serious,  and  will  necessitate  a  guarded 
prognosis  as  regards  ultimate  cure. 

Epididymitis  is  a  most  serious  complication,  since  by  it  the  function  of  the 
testicle  may  be  destroyed,  and  cases  of  double  epididymitis  must  be  looked  upon 
with  gravity,  since  this  condition  is  responsible  for  a  large  number  of  cases  of 
sterility.  With  a  view  to  preventing  this  possible  contingency,  the  most  careful 
treatment  is  required  until  all  traces  of  the  thickening  of  the  epididymis  have 
subsided  ;  this  is  effected  by  means  of  pressure  and  heat,  best  applied  by 
means  of  a  JuUien's  bandage.  No  positive  opinion  as  to  the  patient's  matri- 
monial prospects  should  be  given  until  an  examination  of  the  semen  has  been 
made  and  the  presence  of  active  spermatozoa  ascertained.  Prostatitis,  either 
acute  or  chronic,  is  a  further  complication  of  the  disease  ;  the  prognosis  of  acute 
prostatitis  is  good,  and  the  condition  usually  subsides  in  a  week  or  ten  days, 
though  it  may  form  an  abscess  which  will  require  to  be  opened. 

Chronic  prostatitis  is  a  common  complication  of  a  posterior  gonorrhoea,  is  a 
most  difficult  condition  to  treat  satisfactorily,  and  is  responsible  for  a  large 


GONORRHCEA 


number  of  cases  of  sexual  hj'pochondriasis.  Massage  of  the  prostate  gland  per 
rectum,  and  subsequent  instillations  into  the  prostatic  urethra  of  20  min.  of 
solution  of  nitrate  of  silver,  5  to  20  gr.  to  i  oz.,  by  means  of  a  Guyon's 
syringe,  is  the  treatment  from  which  the  most  satisfactory  results  may  be 
expected. 

Seminal  vesicuUtis  is  a  not  infrequent  concomitant  of  chronic  prostatitis, 
and  may  yield  to  similar  treatment,  though  massage  of  the  seminal  vesicles  is 
a  more  difficult  procedure  than  is  that  of  the  prostate.  In  this  condition, 
catheterization  of  the  common  ejaculatory  ducts  through  the  urethroscopic  tube 
has  been  recommended  and  carried  out  with  success,  but  this  is  a  process  of 
considerable   difficulty,   and  one  requiring  much  technical  skill. 

Gonorrhceal  cystitis  is  another  complication  of  a  posterior  gonorrhoea,  and 
is  commonly  located  at  the  neck  of  the  bladder,  although  the  whole  of  the 
vesical  mucous  membrane  may  be  affected.  Treatment  by  rest  in  bed,  by  the 
administration  of  balsamics,  urotropine,  and  helmitol  internally,  and  later  by 
irrigations  of  the  bladder  with  weak  antiseptic  solutions,  will  usually  ensure  the 
disappearance  of  this  symptom,  but  occasionally  the  infection  spreads  upwards 
to  the  pelvis  of  the  kidney,  a  region  in  which  local  applications  are  not  available 
except  by  means  of  the  ureteric  catheter. 

Gonorrhceal  ophthalmia  in  the  new-born  or  in  the  adult  is  a  most  serious 
comphcation,  but  is  one  which  usually  yields  to  treatment  by  local  applications 
of  nitrate  of  silver  solutions  or  its  modifications,  such  as  protargol,  followed  by 
astringent  lotions  and  the  application  of  boracic  lotion.  The  prophylactic 
treatment  of  the  sound  eye  is  a  necessary  accompaniment  of  the  treatment. 
Ophthalmia  neonatorum  is  a  disease  which  should  be  averted  bj^  prophylactic 
measures,  but  is  a  condition  which  when  recognized  early  should  yield  to  applica- 
tions of  solutions  of  nitrate  of  silver  or  of  its  compounds. 

In  addition  to  the  complications  of  gonorrhoea  due  to  a  direct  infection  with 
the  gonococcus,  there  may  be  a  systemic  infection  from  that  organism  or  from 
its  toxins,  giving  rise  to  gonorrhceal  arthritis,  keratoses,  irido-choroiditis,  endo- 
carditis, pericarditis,  peritonitis,  pleurisy,  and  meningitis,  really  forms  of  gonor- 
rhceal septicagmia. 

It  is  in  the  sj^stemic  manifestations  of  gonorrhoea  rather  than  in  the  local  ones 
that  vaccine  therapy  is  chiefly  indicated,  though  it  has  been  found  to  be  beneficial 
in  all  stages  of  the  disease.  Either  stock  or  autogenous  vaccines  may  be  used, 
but  in  either  case  their  introduction  is  liable  to  be  followed  by  both  local  and 
general  reactions,  the  local  ones  manifesting  themselves  in  redness  and  swelling 
at  the  site  of  injection,  and  the  constitutional  ones  in  rise  of  temperature  and  in 
an  increase  of  pain  in  the  region  affected  by  the  gonorrhceal  invasion.  In  our 
experience,  rectal  injections  of  antistreptococcic  serum  yield  most  satisfactory 
results  in  cases  of  gonorrhceal  arthritis  or  other  forms  of  septicajmia,  10  c.c.  of 
the  serum  being  introduced  per  rectum  daily  for  a  fortnight  or  three  weeks. 
The  prognosis  in  gonorrhceal  arthritis  must  be  a  very  guarded  one,  as,  in  a  certain 
proportion  of  cases,  the  affected  joints  are  permanently  injured,  and  some 
limitation  of  movement  will  be  the  result.  In  addition  to  the  vaccine  treatment, 
local  measures  such  as  Bier's  passive  congestion  may  be  tried,  and  in  the  case 
of  the  knee  joint,  early  aspiration  may  be  practised,  followed  by  counter-irritation 
and  passive  movement. 

Excision  of  the  seminal  vesicles  has  been  attended  with  success  in  cases  of 
gonorrhceal  arthritis  on  the  assumption  that  in  the  vesiculoe  is  situated  the  focus 
of  systemic  infection,  and  in  justification  of  this  somewhat  severe  operation  it  is 
undoubtedly  the  case  that  seminal  vesiculitis  is  a  frequent  accompaniment  of 
gonorrhceal  arthritis.  /.  Ernest  Lane. 


INDEX    OF    PROGNOSIS 


GONORRHCEA  IN  THE  FEMALE. — Before  considering  the  results  of 
infection  in  particular  sites,  it  will  be  well  to  make  a  few  observations  on  gonor- 
rhoea irrespective  of  the  locahzation.  Speaking  generally,  the  ill  effects  are 
less  obvious  than  in  the  case  of  the  male,  but  are  even  more  disastrous  and 
serious,  especially  when — as  happens  in  at  least  50  per  cent  of  all  cases — the 
infection  reaches  the  cervix  and  is  an  ascending  one.  Considerable  lesions  in 
the  urinary  tract  are  decidedly  exceptional.  The  lower  genital  tract  is  little 
liable  to  severe  gonococcal  lesions,  and  when  attacked  readily  recovers.  In 
the  first  week  or  two  after  infection,  no  definite  opinion  concerning  the  ultimate 
prognosis  can  be  made  in  individual  cases  ;  under  palliative  treatment  the 
mischief  has  become  localized  at  the  end  of  a  fortnight,  and  the  prognosis 
varies  with  the  lesion  then  present  and  its  site. 

Gonorrhcea  and  Sterility. — It  is  estimated  that  70  per  cent  of  all  sterile 
marriages  are  the  result  of  gonorrhcea,  either  in  the  husband,  the  wife,  or  both. 
Of  women  who  have  had  gonorrhoea,  it  is  found  that  30  per  cent  are  sterile. 
'  One-child  '  sterility  is  pretty  generally  regarded  as  resulting  from  the  exten- 
sion of  gonorrhoeal  infection  during  the  puerperium. 

Giles^  found  that  in  the  cases  he  operated  upon  for  pelvic  inflammation  or 
tubal  disease  who  were  under  forty  years  of  age  and  married,  25  per  cent  subse- 
quently became  pregnant.  Of  these,  19  women  had  25  children,  and  5  other 
women  had  miscarriages. 

Norris^  records  that  in  68  cases  treated  surgically,  but  none  of  which  was 
sterilized,  17  of  those  under  forty  years  of  age  became  pregnant,  and  4  others 
had  miscarriages. 

The  chance  of  infecting  the  child  when  gonorrhoeal  women  bear  children  is 
to  be  regarded  as  serious.  It  is  variously  estimated  that  10  to  30  per  cent  of 
all  blindness  in  the  world  results  from  this  cause. 

Prognosis  as  affected  by  Treatment. — Chief  interest  in  the  treatment  of 
gonorrhoea  centres  round  the  different  methods  adopted — whether  reliance  is 
to  be  placed  upon  vaccines,  or  whether  the  older  methods  of  local  applications 
and  douches  are  to  be  almost  the  only  hope  of  the  physician. 

Concerning  the  value  of  vaccines,  the  widest  variation  in  opinion  is  found, 
both  as  to  their  use  in  general  and  in  localized  lesions.  The  weight  of  opinion 
tends  to  the  views  that  chronic  lesions  react  better  than  acute  ;  that  success 
is  more  likely  to  follow  their  administration  in  general  infections  than  in 
localized  lesions  ;  that  the  vulvovaginitis  of  children  is  benefited  ;  and  that 
many  cases  of  chronic  arthritis  react  to  vaccines.  Pelvic  disease  of  the  tubes 
or  peritoneum  does  not  react  to  vaccine  treatment. 

Prognosis  in  Particular  Sites. 

Vulvovaginitis. — The  infection  in  children  is  usually  acute,  and  would  appear 
to  react  better  to  vaccines  than  to  simple  palUative  naeasures.  The  following 
table  is  taken  from  Norris,  and  gives  the  result  of  vaccine  treatment ;  the 
second  series  in  each  instance  was  reported  after  an  interval  of  five  years  : — 

Results    of    Palliative    and    of    Vaccine    Treatment 
OF  Vulvovaginitis  in  Children. 


Reporter 

Cases 

Cured 

Improved 

Not  benefited 

Butler^ 
Butler* 
Hamilton^  - 
Hamilton*  - 

12 
25 
67 
84 

10 
0 
0 

76 

2 
25 
6i 

0 

0 
0 
1 

5  (&31ost) 

GONORRHCEA     IN     THE    FEMALE 


203 


Hamilton®  shows  the  comparative  results  obtained  in  gonorrhoeal  vaginitis 
of  the  adult,  according  as  douching  or  vaccine  therapy  was  employed,  and  the 
duration  of  treatment. 


Respective  Results  of  Irrigation  and  Vaccine  Treatment 
OF  Vaginitis  in  Adults. — [Hamilton.) 


Treatment 

Cases 

Cured 

Not   cured 

Lost 

Cured 

Irrigation 
Vaccines 

260 
84 

158 
76 

53 
5 

49 
3 

per  cent 

60 
90 

Average  length  of  time  under  treatment  by  irrigation,  101  months. 
Average  length  of  time  under  treatment  by  vaccines,  17  months. 

The  results  in  the  above  tables  must  be  taken  as  much  above  the  average, 
and  unlikely  to  follow  the  administration  of  stock  vaccines. 

Condylomata. — The  treatment  of  condylomata  is  in  general  uniformly  good, 
although  the  larger  masses  require  more  extensive  cauterization,  often  at 
repeated  intervals. 

Bartholin's  Gland. — Once  infection  of  the  gland  has  occurred,  treatment  has 
to  be  prolonged.  Often  an  apparent  cure  results,  within  a  month  or  two,  in  a 
recrudescence  of  inflammation  and  swelhng,  with  or  without  discharge.  In  the 
more  stubborn  cases  a  Bartholinian  cyst  or  abscess  develops  ;  the  results  of 
treatment  by  excision  leave  nothing  to  be  desired. 

Urethritis  and  Cystitis. — Although  by  accurate  examination  it  can  be  deter- 
mined that  at  least  50  per  cent  of  all  cases  of  gonorrhoea  show  the  diplococcus 
present  in  the  urethra,  it  is  in  comparatively  few  instances  that  symptoms 
indicative  of  urethritis,  and  still  more  rarely  of  cystitis,  result  from  gonorrhoeal 
infection.  In  all  cases  simple  medical  measures,  such  as  local  applications  and 
irrigations,  are  successful.  Stricture  is  exceedingly  rare  as  a  result.  Herman^ 
was  able  to  collect  only  eight  cases  from  the  medical  literature,  and  it  is  doubt- 
ful if  all  of  these  were  certainly  gonorrhoeal.  Balsamic  remedies  such  as  cubebs 
and  copaiba  are  of  no  use  in  women.  Alcohol  and  sexual  irritation  are  con- 
ducive to  a  recrudescence. 

In  rare  instances  the  infection  lodges  in  Skene's  tubules,  and  there  is  formed 
a  peri-urethral  abscess,  which  is  readily  and  efficiently  treated  by  surgical  means. 
Gonorrhoeal  pyelitis  has  occurred  following  a  cystitis,  but  is  rare. 

Cervix. — The  cervix  is  one  of  the  most  unfortunate  sites  in  which  to  have 
the  infection  localized,  owing  to  the  depth  of  gland  tissue  and  the  coating  of 
mucus  ;    most  remedial  applications  entirely  fail  of  their  object. 

Figures  as  to  the  relative  value  of  the  different  treatments  are  lacking.  The 
application  of  caustic  chemicals,  or  even  of  the  actual  cautery,  when  persisted 
in  over  a  long  time  and  with  care,  appears  to  end  more  or  less  successfully  in 
the  majority  of  cases,  but  the  treatment  may  be  necessary  for  months  and 
even  years. 

The  number  of  cases  of  cervicitis  in  which  vaccines  have  been  employed  are 
few,  but  in  some  cases  in  which  local  applications  have  failed,  the  result  of  a 
vaccine  has  been  good. 

Finally,  in  certain  cases  when  the  mucosa  extroverts  and  a  definite  erosion 
results,  it  will  be  found  that  the  best  results  follow  surgical  measures. 

Whatever  measures  are  adopted,  there  usually  results  a  mild  chronic  cervi- 
citis, perhaps  owing  to  a  superimposed  pyogenic  infection,  with  a  degree  of 
leucorrhoea  which  may  be  intermittent  or  vary  in  intensity  from  time  to  time. 


204  INDEX    OF     PROGNOSIS 

Uterus. — Endometritis  is  usually  obscured  by  the  associated  pelvic  inflamma- 
tion. The  condition  ends  in  a  few  cases  in  a  chronic  metritis  leading  to  fibrosis 
of  the  uterus. 

Salpingitis  and  Pelvic  Inflammation. — In  the  acute,  and  more  especially  in 
the  subacute,  stages,  opinion  is  divided  as  to  the  value  of  rest  and  medical 
therapeutics  ;  all  are  agreed  that  many  cases  which  now  come  to  operation 
might  have  been  cured  by  purely  medical  means  if  the  treatment  had  been 
continued  some  time  longer.  This  is  borne  out  by  figures  from  Prochownick 
which  we  shall  quote  presently,  and  a  rough  comparison  may  be  made  with  the 
results  of  operative  treatment. 

Kronig  (quoted  by  Stoehler^)  states  that  of  38  cases  treated  entirely  by 
palliative  measures,  32  were  able  to  go  about  their  work  after  a  varying  period 
of  treatment  by  rest. 

The  most  valuable  figures  are  those  of  Prochownick®  ;  he  treated  his  cases 
with  surgical  measures  when  necessary,  and  sent  many  to  a  sanatorium  for 
further  treatment  when  thought  advisable,  and  above  all,  the  cases  treated 
were  all  watched  for  at  least  five  years  :  Of  420  cases  treated,  he  records  160. 
or  38  per  cent,  of  permanent  cures  ;  without  any  operation  the  permanent 
cures  were  80,  or  19  per  cent.  Of  the  160  cures,  70  per  cent  were  treated  for 
over  four  weeks — some  of  them  for  six  weeks — and  later  sent  to  a  sanatorium. 
Of  the  160  cures,  85,  or  55  per  cent,  remained  well  after  the  one  course  of 
treatment ;  27  remained  well  after  a  second  course  of  treatment ;  16,  or  10  per 
cent,  had  pus  collections  which  were  evacuated  ;  10  required  operation  for 
adhesions  from  tliree  to  five  years  after  treatment  (no  tube  or  parts  being 
removed). 

Giles,  ^practising  conservative  surgery,  had  the  following  results  :  cases  treated, 
132;  cured,  120.  These  figures  are  perhaps  optimistic.  Many  said  to  be  cured 
suffer  from  adhesions,  producing  abdominal  pain  of  greater  or  less  severity. 
Even  after  operation,  adhesions  are  re-formed.  Where  both  appendages  are 
diseased  and  extensive  peritoneal  inflammation  exists,  it  is  important  that 
the  uterus  be  either  fixed  forward  or  removed  ;  there  are  numerous  instances 
of  surgical  measures  being  regarded  as  a  failure  owing  to  retro- displacement 
with  fixation  of  the  uterus  subsequently  arising. 

As  regards  vaccine  treatment,  Heymann  and  Moos'^"  used  vaccines  in  44  cases 
of  acute  tubal  infection.  The  results  were  very  good  in  27  per  cent,  fair  in  41 
per  cent,  and  a  failure  in  20  per  cent.  All  treatment  was  supplemented  by 
local  measures,  so  that  it  is  not  obvious  how  much  is  directly  attributable  to 
vaccines.  In  9  cases  of  chronic  tubal  infection  there  were  7  distinct  failures. 
They  state  that  vaccines  were  also  found  useless  in  cer\dcal  and  urethral 
infections. 

Peritonitis. — In  the  pelvic  peritonitis  which  follows  acute  gonorrhoeal  infec- 
tion, the  results  of  surgical  interference  are  so  uniformJy  good  in  the  early 
stages,  that  palliative  measures  are  seldom  continued  when  there  is  any  fear 
of  the  peritonitis  becoming  general. 

The  result  of  operation  in  the  general  peritonitis  that  ensues  upon  the  rupture 
of  a  tube  is  more  serious,  as  the  following  figures  show.  Bovec,^^  56  cases  : 
24  recovered,  32  died.     Bonney,^^  45  cases  :    23  recovered,  22  died. 

Further,  the  earlier  the  operation  the  better  the  prognosis.  Of  those  operated 
on  during  the  first  twelve  hours,  14  recovered,  6  died  ;  after  twenty-four  hours, 
I  recovered,  none  died  ;    after  forty-eight  hours,  i  recovered,  4  died. 

Arthritis. — Norris"  makes  the  following  observations  as  to  the  prognosis  in 
joint  lesions. 

In   the   acute  form  of   the   disease   the   occurrence   of   suppuration  and   the 


GOUT  205 

destruction  in  part  of  the  joint  is  not  infrequent ;  and  in  the  chronic  type 
partial  ankylosis  is  rarer  in  the  case  of  children.  Serous  effusions  limited  to 
intra-articular  structures  do  best,  but  even  in  these  relapses  are  frequent. 

Norris,^  quoting  and  summarizing  the  results  obtained  by  a  whole  series  of 
authors,  gives  the  following  figures  respecting  the  results  of  vaccine  treatment — 
211  cases  :    84  cured,  102  improved,  25  not  benefited. 

Heymann  and  Moos^"  think  vaccines  of  great  benefit  ;  in  6  cases  the  results 
were  :    2  very  good,  3  good,  i  failure. 

The  opinion  appears  general  that  medical  and  local  applications  should  be 
continued  during  the  administration  of  vaccines  in  all  cases. 

Puerperal  Infection. — Findley^^  states  that  i  case  in  every  6  is  due  to  gonor- 
rhoea. The  puerperal  infection  rarely  causes  death,  but  it  is  often  complicated 
by  the  presence  of  streptococci.  Often  the  infection  recurs  in  each  puerperium 
and  runs  a  similar  course,  lasting  a  few  days,  with  high  temperature  and 
slight  discharge  ;  occasionally  the  fever  is  more  prolonged.  The  more  common 
end-result  is  a  one-child  sterility  or  a  pyosalpinx. 

References. — ^Jour.  Obst.  and  Gyn.  1910,  March  ;  ^Norris,  Gonorrhcza  in  Women, 
1913  \^Pract.  1905,  589  ;  *Jour.  Ainer.  Med.  Assoc.  1910,  U,  1301 ;  ^Infect.  Dis.  1908,  v.  158  ; 
^Jour.  Amer.Med.  Assoc.  1910,1196;  ''Trans.  Obst.  Soc.  London,  xxix  ;  ^Monats.  f.  Geb. 
u.  Gyn.  1903,  xvii  ;  *  Ibid.  1909,  No.  20,  453  ;  ^'^Monats.  f.  Geb.  u.  Gyn.  1913,  Hft.  5  ; 
"Swrg.  Gyn.  and  Obst.  1910,  x,  405  ;   ^^Ibid.  1909,  ix,  542  ;   ^^Diseases  of  Women,  1914. 

Bryden  Glendining. 

GOUT. 

Acute  Gout. — The  danger  to  life  in  an  acute  attack  is  practically  negligible 
unless  acute  inflammatory  changes  are  set  up  in  internal  organs,  as  a  result  of 
chill  or  injudicious  treatment  of  the  articular  lesion.  Violent  cerebral,  gastric, 
or  cardiac  symptoms  may  be  set  up  in  this  way,  and  then  the  immediate  outlook 
becomes  very  grave  indeed.  The  predominant  symptoms  indicating  these 
changes  are  severe  headache  and  violent  delirium,  acute  epigastric  pain 
associated  with  obstinate  vomiting,  and  signs  of  acute  pericarditis  with  a  rapid, 
intermittent  pulse  and  a  tendency  to  syncope.  The  prognosis  is  worse  if  there 
is  a  strong  hereditary  history,  and  if  the  attack  occurs  early  in  life. 

Chronic  Gout. — As  a  rule,  in  this  condition,  the  main  danger  lies  in  the  gradual 
onset  of  complications,  the  most  important  of  which  are  in  the  renal  and  cardio- 
vascular systems.  Of  the  former,  the  contracted  gouty  granular  kidney  has 
to  be  considered.  The  prognosis  in  this  is  probably  ranch  the  same  whether 
it  is  produced  by  the  gouty  diathesis,  or  by  any  other  etiological  factor.  It 
leads  to  death  mainly  along  three  lines,  viz.,  firstly,  by  cardiovascular  change  ; 
secondly,  by  the  incidence  of  superadded,  often  terminal,  infections  ;  and  thirdly, 
by  uraemic  manifestations.  From  an  analysis  made  by  the  writer  from  post- 
mortem hospital  records  of  156  consecutive  cases  of  patients  who  died  with 
chronic  interstitial  nephritis,  the  following  figures  showing  the  causes  of  death 
were  obtained  :  uraemia,  21  ;  cerebral  haemorrhage,  41  ;  cardiac  failure,  14  ; 
cardiac  failure  associated  with  much  bronchitis,  7  ;  the  supervention  of  acute 
nephritis  with  oedema  of  the  lungs,  2  ;  supervention  of  acute  nephritis  with 
uraemia,  2  ;  cerebral  thrombosis,  4  ;  aneurysm,  2  ;  oedema  of  lungs,  2  ;  sub- 
dural haemorrhage,   i. 

Death  occurred  in  a  large  number  as  the  result  of  superadded  terminal 
infections,  thus  :  28  died  from  lobar  pneumonia,  3  from  bronchopneumonia, 
4  from  pericarditis,  4  from  phthisis,  4  from  empyema,  2  from  general  miliary 
tuberculosis,  i  from  the  combination  of  pericarditis,  pleurisy,  peritonitis,  and 
pneumonia,  i  from  pericarditis  with  pleurisy,  i  from  pleurisy  alone,  and  i 
each  from  pneumonia  and  empyema,  pneumonia  and  pericarditis,  and  pul- 
monary gangrene. 


2o6 


INDEX    OF    PROGNOSIS 


The  following  percentages  are  obtained  from  these  figures  :  death  from 
uraemia,  147  per  cent  ;  from  indirect  changes  in  other  organs,  46-2  per  cent  ; 
from  secondary  infections,  33'3  per  cent ;  accidental  causes,  e.g.,  carcinonaa, 
poisons,  5 "8  per  cent. 

The  possibility  of  the  incidence  of  a  gouty  venous  thrombosis,  with  the 
occurrence  of  pulmonary  embolism  leading  to  a  fatal  result,  must  always  be 
borne  in  mind.  In  spite  of  all  these  dangers,  the  members  of  a  gouty  family 
are  frequently  long  livers. 

With  reference  to  the  prognostic  value  of  changes  in  the  fundus,  a  renal 
retinitis  has  the  same  serious  significance  as  in  other  forms  of  nephritis,  but  a 
unilateral  haemorrhagic  retinitis,  with  extravasations  of  blood  which  may  burst 
into  the  vitreous,  sometimes  occurs.  These  haemorrhages  are  most  probably 
due  to  thrombosis  of  the  retinal  vein  and  do  not  carry  the  same  outlook  as 
renal  retinitis.  It  is  too  early  to  say  whether  the  prognosis  of  the  vascular 
and  other  lesions  in  gout  will  be  materially  modified  by  the  use  of  radium, 
emanations,  or  by  thorium.  /.  R.  Charles. 

HiEMATOCELE,  PELVIC. — {See  Ectopic  Pregnancy.) 

H.ffiMATOMA,  ARTERIAL. — Recent  rupture  of  an  artery,  subcutaneously 
or  after  a  punctured  wound,  is  a  very  serious  injury  which  urgently  demands 
surgical  interference  to  prevent  gangrene  or  fatal  loss  of  blood.  There  has 
been  some  difference  of  opinion  as  to  which  operative  procedure  will  lead  to 
the  best  results.  Thus  Guibe  has  collected  from  the  literature  78  cases  of 
rupture  of  the  axillary  vessels  in  association  with  dislocation  of  the  shoulder, 
57  being  due  to  efforts  at  reduction,  especially  by  extension  or  the  heel-in-axilla 
methods.  One  would  have  expected  that  incision  and  tying  the  vessel  would 
have  given  better  results  than  ligature  of  the  subclavian,  and  it  also  allows 
of  reduction  of  the  dislocation  ;  but  in  the  records  the  incision  method  shows 
a  mortality  of  31  per  cent  and  44  gangrened,  whilst  ligature  of  the  subclavian 
cured  80  per  cent  and  only  20  per  cent  became  gangrenous.  The  figures  are, 
however,  too  few  to  prove  the  point,  and  go  back  into  the  pre-antiseptic  era. 

A  larger  and  more  reliable  body  of  statistics,  which  we  owe  to  the  researches 
of  Monod  and  Vanwerts,  show  that  the  best  results  in  every  situation  were 
obtained  by  restorative  methods  or  by  compression  of  the  feeding  artery, 
opening  the  haematoma  and  ligature  in  situ.  The  results  are  shown  in  this 
table  : — 


Method 

Cases 

Cured 

Died 

Gangrene 

Failed 

Proximal  Ligature 
Incision         .         .         .         .         . 
Obliterative  Aneurysmorrhaphy    - 
Conservative  operations 

41 

157 

1 

39 

per  cent 

60-5 
81-5 
100 

87 

per  cent 

14-6 
10 

5 

per  cent 

7 '5 
6-5 

5 

per  cent 

12 
1-2 

"5 

With  reference  to  the  individual  vessels,  the  same  writers  relate  17  cases  of 
injury  to  the  Carotid,  of  which  6  died  and  4  developed  cerebral  troubles. 

Four  cases  of  wound  of  the  Brachial  artery  and  vein  all  did  well.  Although 
ligature  of  the  Femoral  artery  has  a  bad  reputation  for  causing  gangrene,  only 
2  out  of  56  showed  this  complication,  and  in  one  of  these  the  vein  was  injured. 
In  9  cases  the  artery  and  vein  were  both  tied  without  causing  gangrene.  Most 
of  these,  however,  were  superficial  femoral  cases. 


HEMOPHILIA  207 


The  Popliteal  was  much  more  disastrous  ;  9  out  of  14  were  gangrenous  before 
operation,  and  4  more  became  so  afterwards.  In  several  of  these  the  vein  was 
also  injured. 

References. — Guibe,  Rev.  cle  Chir.  1911,  580;  Monod  and  Vanwerts,  Ibid.  1911, 
663.  A.  Rendle  Short. 

HAEMOPHILIA. — It  may  be  well  to  make  it  clear  at  the  outset  what  we 
understand  by  this  condition.  It  may  be  defined  as  a  disease,  usually  congenital, 
characterized  by  a  tendency  to  haemorrhage,  which  may  be  spontaneous  or  in 
connection  with  wounds  or  injuries.  The  disease  affects  males  in  the  great 
majority  of  instances,  and  the  usual  history  is  that  the  tendency  is  transmitted 
through  the  females,  who  are  not  themselves  bleeders. 

Bullock  and  Fildes  have  gone  so  far  as  to  deny  the  existence  of  de  novo  cases, 
or  of  definite  symptoms  appearing,  in  the  female. 

We  are  inclined  to  think  they  have  arrived  at  this  conclusion  by  the  somewhat 
arbitrary  course  of  disparaging,  or  disregarding,  evidence  to  the  contrary,  and 
we  may  say  at  once  that  we  have  seen  and  treated  patients  whose  history  and 
symptoms  have  convinced  us  that  cases  without  hemophilic  ancestry  do  occur, 
and  that  severe  haemophilia  may  affect  females. 

Prognosis  may  be  considered,  (i)  from  the  point  of  view  of  the  expectation 
of  life  or  recovery  of  the  patient;  and  (2),  in  view  of  the  hereditary  aspects  of 
the  disease,  as  regards  the  chances  of  a  patient  transmitting  it  to  posterity. 

I.  Prognosis  as  regards  Patient. — This  is  always  grave,  especially  in  young 
subjects.  As  a  rule,  the  condition  does  not  show  itself  within  the  first  twelve 
months  of  life.  Some  cases,  however,  are  fatal  shortly  after  birth  from  bleeding 
of  the  umbilical  cord  ;  the  bleeding  may  be  immediate  or  may  not  begin  till 
the  third  day  or  later  ;  it  may  be  arrested,  but  is  sometimes  fatal  within  twenty- 
four  hours. 

The  risk  to  life  diminishes  after  early  childhood.  The  child  and  his  attendants 
learn  to  appreciate  the  danger  of  even  slight  knocks  or  scratches ;  and  the 
essential  defect  seems  to  lessen.  The  seriousness  of  the  outlook  is  illus- 
trated by  Grandidier's  statistics.  Out  of  152  boy  haemophilics,  81  died  before 
the  end  of  the  seventh  year. 

The  longer  a  patient  lives  the  greater  is  his  chance  of  outgrowing  the  tendency. 
In  many  of  the  surviving  cases  it  has  disappeared  at  the  age  of  twenty  or  thirty  ; 
but  other  cases  reach  a  ripe  old  age  and  exhibit  symptoms  to  the  end. 

It  cannot  be  said  that  much  can  be  done  by  treatment  to  diminish  the  tendency 
to  bleeding.  The  administration  of  lime  has  been  lauded,  but  Addis  has  thrown 
grave  doubt  on  the  scientific  reasoning  on  which  this  treatment  is  based ;  he 
holds  that  enough  ionisable  calcium  to  affect  clotting  cannot  be  absorbed. 
Definite  improvement  has  followed  the  administration  of  horse  serum.  The 
administration  is  made  intravenously,  since  the  elastic  recoil  of  the  venous  wall 
and  skin  form  an  efficient  bar  to  local  bleeding.  The  injection  of  Witte's  peptone 
has  not  been  tried  often  enough  for  conclusions  regarding  its  efficacy  to  be  stated. 
It  is  indeed  a  matter  of  great  difiiculty  to  form  an  opinion  regarding  the  efficacy 
of  any  line  of  general  treatment,  since  the  tendency  to  bleeding  shows  such 
extraordinary  variations  in  the  same  patient  at  different  times.  After  a  serious 
or  even  dangerous  haemorrhage,  the  coagulability  of  the  blood  may  increase  to 
a  degree  approaching  or  reaching  that  of  health,  and  this  result  may  be  ascribed 
to  the  last  line  of  treatment  employed.  Residence  in  a  warm  climate  seems  to 
diminish  the  hsemorrhagic  tendency  in  some  instances. 

There  is  no  doubt  that  prognosis  in  haemophilia  has  improved,  owing  to  recent 
discoveries  in  connection  with  the  coagulation  of  the  blood.     These  have  resulted 


2o8  INDEX     OF    PROGNOSIS 

in  the  addition  to  our  armamentarium  of  the  means  of  dealing  locally  with  acces- 
sible haemorrhages,  means  which  were  not  previously  available.  Addis  has  shown 
that  the  diminished  coagulability  of  the  blood  is  due  to  a  great  delay  in  the 
interaction  between  prothrombin  and  lime,  which  forms  thrombin.  The  throm- 
bokinase  which  is  supplied  by  the  damaged  tissues  may  be  washed  away  in  the 
blood,  escaping  from  the  wound  before  it  has  had  time  to  cause  the  prothrombin 
and  lime  to  unite  to  form  the  thrombin  which  determines  the  change  from 
fibrinogen  to  fibrin.  The  existence  of  a  layer  of  fibrin  on  the  edges  of  a  wound 
may  indeed  play  an  important  part  in  preventing  access  of  thrombokinase  to  a 
bleeding  point  in  the  centre  of  the  wound.  The  indication  in  such  a  case, 
therefore,  is  to  remove  coagula  from  a  wound  which  is  still  bleeding  and  apply 
to  it  an  abundance  of  thrombokinase. 

Thrombokinase  can  be  obtained  by  making  an  extract  of  chopped  thymus  or 
testis  with  o-g  per  cent  saline  solution  to  which  a  trace  of  sodium,  carbonate  has 
been  added. 

BuswelP  has  stated  that  a  powerful  extract  of  thrombokinase  can  be  made  by 
washing  sheep's  fibrin  in  tap-water  till  it  is  haemoglobin-free,  and  then  kneading 
about  20  grams  of  the  wet  fibrin  in  300  c.c.  of  distilled  water.  So  far  as  we  are 
aware,  this  extract  has  not  been  tried  in  practice. 

These  physiological  styptics  are  more  efficacious  than  those  which  depend  on 
astringent  or  escharotic  action,  and  moreover  their  use  is  not  followed  by  the 
danger  of  recurrence  of  the  haemorrhage  which  sometimes  takes  place  when  an 
eschar  separates. 

Haemorrhages  are  not  alone  dangerous  qua  haemorrhage.  Adherent  clots  in 
the  posterior  nares  and  among  the  teeth,  and  the  presence  of  decomposing  blood 
in  the  stomach  and  bowel,  may  lead  to  great  discomfort,  and  sometimes  to 
marasmus  and  death. 

Haemorrhages,  and  haemo-serous  effusions  into  joints,  are  not  dangerous  to 
life,  but  may  lead  to  permanent  incapacity.  They  are  often  imperfectly  absorbed, 
and  frequently  recur,  with  the  result  that  adhesions,  erosions,  and  osteo- arthritis, 
with  subsequent  ankylosis  of  varying  degree,  may  be  occasioned.  Cases  of 
fracture  in  haemophilia  have  been  recorded.  A  large  effusion  takes  place,  but 
satisfactory  union  usually  occurs. 

Menstruation  and  parturition  in  non-haemophilic  females  of  bleeder  stock  arc 
not  associated  with  special  danger. 

Even  female  bleeders  seem  frequently  to  escape  serious  consequences  at  these 
times,  but  in  some  cases  menstruation  is  a  recurring  anxiety  ;  in  the  case  of  one 
young  lady  under  our  observation,  a  fatal  result  from  naenorrhagia  has  been 
very  narrowly  escaped  on  three  separate  occasions.  Between  these  serious 
episodes  there  have  been  intervals  of  months  or  years  when  menstruation  has 
given  comparatively  little  trouble,  although  the  susceptibility  to  bruising  and 
accidental  bleedings  has  persisted. 

The  examination  of  the  blood  is  of  comparatively  little  service  in  estimating 
prognosis  in  haemophilia.  We  have  never  found  the  great  reduction  of  poly- 
morphonuclear leucocytes  which  has  been  described  by  authors,  and  in  particular 
by  Wright,  and  if  it  be  remembered  that  many  persons  in  perfect  health  never 
have  more  than  6000  leucocytes  per  c.mm.,  even  the  majority  of  Wright's  own 
figures  are  not  particularly  low.  An  estimation  of  the  coagulability  of  the 
blood  is  sometimes  of  more  service ;  but  when  bleeding  is  in  evidence,  we 
may  take  it  for  granted  that  coagulation  time  is  prolonged,  and  when  bleeding 
is  absent,  the  coagulation  time  in  a  bleeder  may  be  no  longer  than  in  a  healthy 
person. 

An  estimate  of  coagulation  time  might  conceivably  be  usefully  made  before 


HEMORRHOIDS  209 

a  hsemophilic  entered  upon  some  special  undertaking,  such  as  a  journey ;  but 
data  regarding  the  coagulation  time  oefore  haemorrhages  are  very  scanty. 

The  onset  of  spontaneous  haemorrhage,  or  of  increased  liability  to  traumatic 
haemorrhage,  is  sometimes  preceded  by  prodromal  symptoms.  Headache, 
nervous  irritability  and  lassitude,  and  sometimes  even  convulsions,  may  occur; 
but  whether  these  are  associated  with  an  actual  diminution  of  coagulability 
is  a  matter  of  inference  rather  than  of  observation.  In  other  cases,  a  special 
feeling  of  well-being  may  precede  a  spontaneous  haemorrhage. 

To  sum  up,  the  expectation  of  life  in  the  case  of  a  young  bleeder  is  poor.  It 
is  probably  diminished  by  50  per  cent. 

This  state  of  affairs  lessens  with  advancing  age.  The  necessity  for  constant 
care,  the  occurrence  of  joint-effusions  and  their  results,  and  the  incidence  of 
spontaneous  haemorrhages,  reduce  all  but  the  slightest  cases  of  haemophilia  to  a 
condition  of  at  least  semi-invalidism.  The  danger  of  bleeding  from  accessible 
sites  may  be  greatly  diminished  by  the  use  of  physiological  styptics. 

2.  Transmission  of  the  Disease. — The  females  of  hasmophilic  stock  are  fertile 
beyond  the  ordinary,  and  a  study  of  the  genealogy  of  haemophilic  families  shows 
clearly  that  the  great  majority  of  the  male  offspring  of  the  women,  whether  the 
latter  are  themselves  bleeders  or  not,  are  likely  to  be  haemophilics.  Women  of 
haemophilic  stock  should  therefore  be  advised  not  to  reproduce  their  species. 

A  male  bleeder  is  obviously  not  a  fit  and  proper  person  to  assume  the  responsi- 
bilities of  parentage  ;  and  apart  from  his  personal  disabiUty,  there  is  a  definite, 
though  comparatively  slight,  probability  that  he  may  propagate  bleeders. 

The  question  of  marriage  in  non-hasmophilic  males  of  a  bleeder  stock  is  more 
difficult.  The  man  is  under  no  personal  disability,  but  there  is  rather  more  than 
a  moderate  risk  that  he  may  transmit  the  disease.  We  have  published  a 
genealogy  in  which  a  non-bleeder  male  of  hasmophilic  stock  had  two  sons  who 
died  of  haemophilia.  His  non-haemophiUc  daughter  was  twice  married  and  had 
haemophilic  offspring  by  both  husbands.  One  of  her  sons,  a  non-bleeder,  married 
a  healthy  woman  and  had  two  sons  who  died  of  the  disease. 

Reference. — ^Joiir.  Physiol.  1913.  G.  L.  Gulland- 

A.  Goodall. 

HEMORRHOIDS. — A  patient  suffering  from  '  an  attack  of  piles  '  frequently 
asks  whether  he  is  likely  to  get  better  without  operation.  The  answer  depends 
on  the  condition  found. 

Thrombosis  of  an  external  pile,  which  is  very  painful  for  a  few  days,  usually 
gets  quite  well,  and  there  may  never  be  any  further  trouble. 

Bleeding  piles  can  fairly  often  be  relieved,  rather  than  cured,  by  dieting, 
purgatives,  and  local  applications. 

Strangulated  prolapsed  piles,  in  rare  cases,  cure  themselves,  after  a  painful 
illness,  by  gangrene. 

A  patient's  life  is  very  seldom  in  danger  from  haemorrhoids,  but  fatal  embolism 
from  a  thrombosed  pile  has  been  recorded,  and  the  bleeding,  if  unchecked,  might 
even  threaten  Ufe.  The  prospect  of  cure  by  injection  of  carbolic  acid  into  the 
pile,  or  ionization,  is  always  uncertain. 

Results  of  Operation. — There  are  three  operations  in  common  use — namely, 
the  hgature,  the  clamp  and  cautery,  and  the  Whitehead  operations. 

Mortality. — This  is  as  low  as  that  of  any  operation  can  be.  Swinford  Edwards 
and  other  surgeons  have  treated  thousands  of  cases  without  a  death.  At  St. 
Mark's  Hospital,  in  forty  years  up  to  1896,  the  mortality  was  i  in  670  ;  after- 
wards there  were  no  deaths  in  many  years. 

After-discomfort  varies  with  the  method  of  operating.  Pain  is  least  with  the 
clamp  and  cautery  method,  most  after  ligature.     Stay  in  hospital  was,  on  an 

14 


INDEX    OF    PROGNOSIS 


average,  ten  days  after  the  clamp  and  cautery,  twenty-one  after  ligature,  and 
twenty-six  after  Whitehead's  operation. 

The  two  principal  after-troubles  are  stenosis  and  recurrence. 

Stenosis  is  unknown  after  the  cautery  operation  ;  it  occurs  in  slight  degree, 
which  is  of  no  importance,  after  about  a  third  of  the  ligature  cases  and  half  of 
the  Whitehead  cases.  Stricture  requiring  treatment  was  met  \\'ith  in  8  out  of 
loo  patients  on  whom  Whitehead's  operation  had  been  performed. 

Recurrence  is  extremely  rare  if  an  efficient  operation  is  performed  in  the  first 
place  ;  the  writer  has  never  met  with  a  case.  The  end-results  of  piles  operations 
are  almost  invariably  extremely  satisfactory.  In  eighteen  months,  at  St. 
Mark's  Hospital  for  diseases  of  the  rectum,  only  2  recurrences  were  seen,  one  after 
two  years  and  the  other  after  eighteen. 

The  three  operations  ought  not  to  be  regarded  as  mutualty  antagonistic.  The 
clamp  and  cautery  is  best  for  cases  where  there  are  only  a  few  piles  not  involving 
the  skin,  because  burns  of  the  skin  are  painful.  Whitehead's  method  is  to  be 
reserved  for  uncommon  cases  where  the  whole  anal  canal  is  a  mass  of  piles. 

References. —  Anderson,  Brit.  Med.  Jour.  1913,  ii,  1478  ;  Swinford  Edwards, 
Burghard's  System  of  Operative  Surgery  ;  Cripps,  Diseases  of  the  Rectum  and  Anus. 

A.  Rendle  Short. 

HEAD  INJURIES. — The  prognosis  of  a  number  of  conditions  will  here  be 
considered  under  one  heading,  because  it  is  so  difficult  to  distinguish  between 
them  in  practice.  The  aphorism  of  Hippocrates  still  holds  good  :  "  There  is  no 
head  injury  so  trivial  that  it  should  be  despised,  or  so  serious  that  it  should  be 
despaired  of." 

That  the  prognosis  after  a  severe  head  injury  is  very  uncertain  is  evidenced 
by  the  excellent  hospital  rule  always  to  admit  such  cases,  if  possible,  as  a  precau- 
tionary measure  ;  it  is  quite  impossible  to  tell  what  the  outcome  may  be  at 
the  first  examination.  Every  surgeon  knows  of  patients  lying  deeply  comatose, 
who  appeared  to  be  marked  for  death,  who  have  recovered  ;  and,  on  the  other 
hand,  how  often  has  a  resident  imperilled  his  reputation  by  sending  away  a 
patient  with  apparently  nothing  the  matter,  who  subsequently  died.  The  three 
main  causes  of  death  after  this  latter  mistake  are  the  oncoming  of  intracranial 
haemorrhage,  spreading  oedema,  or  meningitis. 

We  shall  consider :  (i)  The  mortality  of  various  head  injuries  ;  (2)  The 
material  for  giving  a  prognosis  in  particular  cases ;    and  (3)  The  possible  sequelcs. 

Mortality  of  Head  Injuries. 


Cases 

Deaths 

Mortality 

per  ceut 

[  Phelps 

28fi 

176 

61 

Fractured    base 

1  Rawling 
""  Battle 
Anderson 

205 
168 

89 
54 

44 
32 

58 

33 

57 

I  Phelps 

116 

41 

34 

Fractured  vertex 

-  \  Rawling 
\  Anderson 

88 

29 

37 

72 

46 

64 

Pistol-shot  wounds  of  brain    -    Phelps 

126 

120 

95 

Extradural    haemorrhage 

with  J  Bowen 

-  "1  (with  operation) 

36 

14 

38 

no  brain  injurv 

25 

3 

12 

Extradural    haemorrhage 

with  ( Bowen    - 

36 

30 

83 

serious  brain  injury 

-  ■(  (with  operation) 

26 

20 

77 

I.  Mortality  of  Head  Injuries. — It  is  of  no  value  to  quote  hospital  statistics 
of  mortality  amongst  head  injuries  in  general,  because  practice  differs  so  much 


HEAD     INJURIES 


as  to  what  type  of  case  is  admitted  and  what  sent  away.  A  few  well-defined 
groups,  however,  furnish  valuable  information.  We  have  figures  for  the  death- 
rate  in  cases  of  fractured  base,  fractured  vertex,  pistol-shot  injury,  and  extra- 
dural haemorrhage. 

Rawling's  cases  are  taken  from  the  records  of  St.  Bartholomew's  Hospital, 
Anderson's  from  the  Cook  County  Hospital,  and  Bowen's  from  those  of  Guy's 
Hospital. 

It  will  be  observed  that  the  figures  for  fractured  base  vary  ;  in  English  practice 
the  mortality  is  probably  under  50  per  cent.  Fractured  vertex  is  less  dangerous  ; 
about  one-third  die.  Out  of  137  cases  of  pistol-shot  of  the  brain  reported  in  a 
New  York  newspaper  for  one  year,  6  recovered  after  operation.  Of  51  cases  of 
extradural  haemorrhage  treated  by  operation,  23  died,  that  is,  less  than  half. 

2.  Data  for  Prognosis. — As  above  remarked,  prognosis  is  absolutely  impossible 
at  the  first  time  of  seeing,  unless  the  patient  is  obviously  moribund  ;  and  even 
if  consciousness  has  not  been  lost,  one  dare  not  say  that  the  injury  is  trivial.  The 
great  majority  of  fatal  cases  die  within  forty-eight  hours,  and  after  a  week  has 
elapsed,  death  is  extremely  improbable  ;   but  even  then  there  is  a  remote  risk. 

Unconsciousness. — The  degree,  depth,  or  prolongation  of  primary  unconscious- 
ness, taken  apart  from  other  signs,  is  of  very  small  value  in  giving  a  prognosis. 
If  other  signs  are  favourable,  recovery  will  almost  certainly  occur,  even  if  the 
patient  is  still  unconscious  at  the  end  of  the  third  or  fourth  day  or  later  (Phelps) . 
Nor  will  such  patients  necessarily  have  grave  after-symptoms,  if  properly  treated. 

On  the  other  hand,  recurring  unconsciousness,  after  a  more  or  less  lucid  interval, 
is  of  very  grave  import,  denoting  intracranial  haemorrhage ;  and  apart  from 
successful  operation,  as  in  cases  of  middle  meningeal  rupture,  the  patient  will 
almost  certainly  die  in  a  few  hours  or  days. 

The  temperature  is  another  sign  of  great  value  (Phelps).  If  it  is  very  subnormal 
from  the  first,  and  shows  no  tendency  to  rise,  the  patient  is  likely  to  die  outright 
of  shock.  Again,  if  at  any  time  it  rises  rapidly,  death  is  probable.  Recovery 
never  occurred  in  Phelps's  cases  when  105°  was  reached,  and  very  few  survived 
whose  temperature  rose  above  104°. 

A  pulse  which  is  slow  and  full,  or  very  quick  and  feeble,  is  generally  rather 
ominous  ;   the  former  usually  indicates  cerebral  compression. 

Hemiplegia  is  a  grave  sign,  if  it  comes  on  from  the  first  ;  it  makes  it  probable 
that  the  cerebral  cortex  is  lacerated. 

Depressed  fracture  of  the  skull  is  a  much  less  grave  injury  in  young  children 
than  in  adults. 

Escape  of  cerebrospinal  fluid  from  one  ear,  in  Rawling's  cases,  did  not  make 
the  prognosis  of  fractured  base  worse  ;  escape  from  both  ears  had  a  mortality 
of  66  per  cent. 

Septic  complications  render  the  death  of  the  patient  certain  if  the  meninges  are 
involved  or  a  subcranial  abscess  forms,  and  therefore  all  cases  with  an  open 
wound  communicating  with  a  fractured  skull  are  in  danger  for  a  week  or  more. 

Late  deaths  are  due  to  sepsis  in  most  instances,  but  it  is  extraordinary  how 
long  a  person  may  live  with  a  haemorrhage  which  eventually  proves  fatal.  Two 
cases  have  come  under  the  writer's  notice  in  which  the  patients  remained  in  a 
variable,  but  rather  stupefied,  condition  for  more  than  a  month  after  an  injury, 
to  the  occiput  in  the  one,  and  to  the  spine  in  the  other — each  dying  at  last  of 
intracranial  haemorrhage,  apparently  dating  from  the  time  of  the  accident,  and 
not  repeated  since. 

Concussion. — A  few  autopsies  on  men  and  animals  have  been  recorded  showing 
that  it  is  possible  for  death  to  result  from  simple  concussion,  without  any  signs 
of  injury  post  mortem. 


INDEX     OF     PROGNOSIS 


Gunshot  or  pistol-shot  injuries  are  almost  invariably  fatal.  Occasionally  a 
bullet  of  low  velocity,  traversing  the  frontal  or  the  occipital  cortex,  fails  to  kill 
the  patient  at  the  time.  Of  40  cases  coming  under  Phelps's  care,  15  died  within 
an  hour,  7  died  under  twelve  hours,  10  between  fifteen  hours  and  forty  days, 
and  8  apparently  recovered.  Even  so,  there  is  a  great  probability  that,  sooner 
or  later,  days,  weeks,  months,  or  years  afterwards,  an  abscess  will  form  if  the 
bullet  is  retained,  and  lead  to  a  fatal  result.  Bullets  in  the  brain  practically 
never  remain  quiescent  in  perpetuo. 

3.  Eventual  Results  of  Head  Injuries. — Within  a  few  days  of  the  accident, 
the  condition  called  cerebral  irritation  may  come  on,  in  severe  cases,  and  last  for 
a  week  or  two. 

Nerve  injuries  associated  with  a  fractured  bone  may  be  immediate  or  remote  ; 
in  either  case  they  usually  clear  up.  Those  cases  in  which  the  paralysis  does  not 
appear  for  a  few  days,  are  always  well  in  two  or  three  months  ;  in  a  few  of  the 
nerve  injuries  seen  immediately  after  the  accident,  the  lesion  is  permanent. 
The  nerves  most  commonlj'  involved  are  the  second,  seventh,  and  eighth. 

A  rare  sequela  of  head  injury  is  rupture  of  the  internal  carotid  artery  into  the 
cavernous  sinus,  causing  pulsating  exophthalmos.  Another  rare  inj  ury  is  traumatic 
cephalhydrocele. 

Functional  defects  of  the  brain  are  the  most  important  sequelse  of  a  head 
injury.  It  is  well  known  that  persistent  headache  or  neuralgia,  vertigo,  loss  of 
memory,  mental  enfeeblement,  or  traumatic  epilepsy  may  follow  such  an  injury, 
and  may  persecute  the  patient  for  the  rest  of  his  life.  Sometimes  he  becomes 
very  sensitive  to  the  effects  of  a  hot  sun,  or  easily  upset  by  a  little  alcohol. 

Crisp  English  followed  up  a  number  of  cases  of  head  injury  treated  at  St. 
George's  Hospital,  and  obtained  the  following  results,  with  which  the  statistics 
of  Rawling  closely  agree. 

No  effects         Slight      Marked  eSeots 

In  100  cases  of  fractured  skull  -  -  -  -        31  50  19 

In  100  cases  of  concussion,  compresssion,  laceration         48  42  10 

In  the  fracture  series,  52  out  of  86  were  earning  their  old  wages,  6  were  totally 
disabled,  and  the  rest  partially.  In  the  second  series,  63  out  of  78  earned  their 
old  wages,  3  were  totally  disabled,  and  the  rest  partially.  The  old  and  the 
young  suffered  most. 

These  unfortunate  end-results  can  be  averted  to  a  large  extent  by  proper 
treatment  at  the  time  of  the  original  injury.  Patients,  especially  of  the  hospital 
class,  are  usually  allowed  to  go  back  to  work  too  soon.  Every  case  of  head 
injury  ought  to  be  kept  quiet  in  bed  on  fluid  diet  until  the  dazed  look  of  the  face 
has  passed  off,  the  blood-pressure  has  risen  to  normal,  and  the  patient  does  not 
sweat,  or  become  giddy,  on  attempting  to  get  up.  After  a  prolonged  unconscious- 
ness, lasting  hours,  the  patient  ought  to  lead  a  quiet  life  for  many  months.  These 
conditions  being  observed,  even  severe  head  injuries  seldom  leave  any  permanent 
trouble. 

Traumatic  Epilepsy. — In  most  cases,  this  is  evidence  of  some  organic  lesion, 
such  as  a  depressed  fracture,  scar  in  the  meninges,  old  blood-clot,  or  tear  of  the 
cortex,  but  sometimes  nothing  can  be  found.  The  results  of  operation  are  not 
very  successful ;  if  a  definite  cause  can  be  removed  the  outlook  is  better.  Much 
depends  upon  keeping  the  patient  absolutely  quiet  for  months  after  the  operation. 
Rawling  records  20  cases  of  his  own,  of  which  2  v.'ere  cured,  14  markedly  improved, 
and  4  not  improved.  Gushing  gives  figures  as  follows  :  free  from  attacks,  12  ; 
attacks  less  frequent,  30  ;    no  improvement,  17  ;    died  of  status  epilepticus,  2. 

References. — Phelps,  Traumatic  Injuries  of  the  Brain  ;  Rawling,  The  Surgery  of 
the  Skull  and  Brain ;  Crisp  English,  Lancet,  1904  ;  Anderson,  Surg.,  Gyn.  and  Obst. 
1914,  522.  A.  Rcndle  Short. 


HERNIA  213 

HERNIA. — Common  as  this  disease  is,  it  is  extraordinary  how  difficult  it 
is  to  find  reUable  reports  in  the  hterature  as  to  the  end-results  of  different 
methods  of  treatment,  in  an  adequate  number  of  cases.  This  is  particularly 
true  with  reference  to  femoral  and  umbilical  hernia,  where  a  prolonged  search 
of  the  surgical  records  of  many  countries  has  been  almost  barren  of  result. 

The  Spontaneous  Cure  of  Hernia. — In  young  children,  up  to  the  age  of  four 
years,  it  is  undoubtedly  possible  to  cure  some  cases,  probably  only  a  minority, 
by  the  use  of  a  truss.  If  this  is  to  be  efficient,  the  hernia  must  never  be  allowed 
to  come  down,  or  all  the  benefit  previously  obtained  is  lost.  What  usually 
happens,  no  doubt,  is  that  the  sac  becomes  very  narrow,  and  it  may  well  be 
that  heavy  straining  in  adult  life  would  reopen  it.  On  this  point  we  lack 
evidence.  But  it  is  quite  certain  that  occasionally  the  neck  of  the  sac  may 
be  obliterated.  This  has  been  verified  by  subsequent  operation  in  one  or  two 
cases.  In  older  children,  or  adults,  cure  of  a  hernia  by  any  other  means  than 
an  operation  is  so  rare  as  to  be  practically  negligible. 

Femoral  hernia  in  infants  is  seldom  cured  by  a  truss. 

The  great  majority'  of  cases  of  umbilical  hernia  in  infants  disappear  after 
a  year  or  so,  if  a  pad  and  bandage  is  worn.  We  do  not  know  if  they  ever 
come  back  again  in  middle  life. 

The  Danger  of  Strangulation. — It  is  very  difficult  to  estimate  the  frequency 
with  which  a  hernia  becomes  strangulated.  Macready  puts  it  at  i'6  per  cent. 
The  proportion  of  cases  of  strangulated  to  those  of  reducible  inguinal  hernia, 
seen  at  a  hospital,  is  perhaps  about  i  in  20  ;  it  is  mere  conjecture  what  proportion 
of  the  herniated  members  of  the  community  who  depend  upon  hospitals  for 
surgery  present  themselves  at  those  institutions  for  examination,  but  probably 
nowadays  it  is  from  a  quarter  to  a  half,  which  agrees  pretty  well  with  Macready 's 
opinion.  Femoral  and  umbilical  hernias  become,  in  proportion,  much  more 
frequently  strangulated. 

The  risks  of  strangulation  in  persons  who  neglect  treatment  year  after  year, 
and  neither  have  an  operation  nor  wear  a  truss,  must  be  much  higher  than 
1-6  per  cent,  because  this  diminishing  class  furnishes  the  majority  of  the 
strangulation  cases.  It  is  a  mere  guess,  but  such  a  patient's  prospects  of  calamity 
are  probably  30  to  50  per  cent  in  the  long  run,  especially  in  the  femoral  and 
umbilical  varieties. 

The  Results  of  Operation. — We  shall  have  to  consider,  (i)  The  operation 
mortality  ;    and  (2)    The  prospects  of  cure  or  relapse. 

I.  The  Operation  Mortality. — This  is,  of  course,  very  low  nowadays.  A  few 
years  back  it  was  by  no  means  inconsiderable  ;  in  four  London  hospitals  in  1890 
it  was  as  high  as  6  per  cent.  To-day,  however,  it  is  only  from  0-25  to  0-5  per  cent 
in  adults,  and  a  little  higher  in  infants  (Bull  and  Coley).  Brenner,  of  Vienna 
(1906),  quotes  2000  cases  with  5  deaths  (0-25  per  cent).  Pott's  enormous 
figures,  running  into  thousands,  for  the  years  1895  to  1903,  show  :  inguinal 
hernia,  0*7  per  cent  died  ;  femoral  hernia,  0-5  per  cent  died  ;  ventral  hernia, 
I -I  per  cent  died. 

Fatalities  are  due  to  sepsis,  pneumonia,  anaesthetic  calamities,  and  totally 
extraneous  occurrences.  Thus,  the  writer  lost  a  patient  who  developed  tj'-phoid 
fever  ;  four  or  five  instances  are  known  in  which  the  femoral  vessels  have  been 
injured,  and  some  of  these  have  been  fatal ;  deaths  have  resulted  from 
wounding  the'  bladder  in  the  sac,  its  presence  not  having  been  recognized  by 
the  operator.  The  writer  has  also  heard  of  urureported  cases  in  which  fatal 
intestinal  obstruction  followed,  due  in  one  instance  to  imprisonment  of  a  loop 
of  bowel  by  the  inverted  sac  in  Kocher's  operation,  and  in  another  to  the  intes- 
tines becoming  entangled  in  adhesions  about  a  filigree. 


214 


INDEX    OF    PROGNOSIS 


2.  The  prospects  of  Cure  after  Operation. 

a.  Inguinal  Hernia.- — The  introduction  of  the  Bassini  method  has  greatly  im- 
proved the  results  in  adults.  The  older  methods  gave  as  high  a  proportion 
of  relapses  as  30  to  40  per  cent  (Bull  and  Coley).  Simple  ligature  of  the  sac, 
without  slitting  up  the  external  oblique,  in  adults,  was  followed  by  recurrence 
in  nearly  30  per  cent  of  the  cases  (Pott).  In  children,  however,  it  is  almost 
always  successful ;    Kellock  had  no  failures  in  52  cases. 

The  Bassini  operation  gives  much  better  results.  Pott's  huge  collection  of 
German  figures,  published  in  1903,  shows  about  10  per  cent  of  recurrences, 
but  other  results  are  much  more  favourable.  Simmonds  gives  the  statistics 
for  1905  for  Massachusetts  Hospital,  the  cases  being  examined  in  1909  ;  in 
113  cases  followed,  there  were  7  per  cent  of  relapses.  Dreesman,  1913,  quotes 
only  2'5  per  cent  out  of  403  operations.  Bull  and  Coley  quote  less  than  i  per 
cent,  but  a  large  number  of  their  patients  were  children.  The  true  figure, 
nowadays,  is  probably  about  i  in  20.  If  relapse  is  going  to  occur,  it  will  usually 
be  in  the  first  year. 

Kocher's  operation  gives  equally  good  results,   according  to  Pott's  figures. 

b.  Femoral  Hernia. — According  to  Bull  and  Coley,  there  were  no  relapses  in 
125  cases  of  operation  for  femoral  hernia,  but  this  merely  means  that  no  patients 
returned  to  them  ;  they  did  not  examine,  or  hear  from,  those  alleged  to  be  cured. 
Pott's  figures  are  by  no  means  flattering  to  surgery  ;  of  158  cases  operated 
on  before  1903,  without  closure  of  the  ring,  more  than  a  third  recurred,  and 
when  the  ring  was  sutured,  nearly  30  per  cent  relapsed.  At  the  Bristol  Royal 
Infirmary,  of  41  cases  treated  by  various  methods,  30  were  well  from  eighteen 
months  to  four  years  afterwards,  and  11  had  relapsed,  that  is,  27  per  cent. 

Making  use  of  the  new  method  of  closing  the  ring  above  Poupart's  ligament, 
C.  A.  Morton  found  7  cases  free  from  recurrence,  and  Fagge  had  3  failures 
after  18  operations. 


Cures 

AFTER  Various 

Operations   for  Hern 

[A. 

iNGflN'At. 

Fl- MORAL 

Reporteb 

Bassini 

Kocher 

Simple 
ligature  of  sac 

Ring  not 
closed 

Ring  closed 

Closure  above 
Poupart's  lig. 

Cases 

Cured 

Cases  1  Cured 

Cases 

Cured 

Cases 

Cured 

Cases 

Cured 

Cases 

Cured 

percent 

per  cent 

percent 

percent 

percent 

percent 

Pott      - 

1851 

90-1 

376 

92-5 

1419 

71-6 

158 

63-3 

155 

71-6 

Bull  &  Colev  - 

837 

99 

Kellock  (chil- 

dren) 

b'l 

100 

Simmonds      - 

113 

93 

Dreesman 

403 

97-5 

Fagge ;  Morton 

20 

88 

Bristol  Royal 

Infirmary  - 

41  cases,  73  per  cent  cured 

c.  Umbilical  or  Incisional  Hernia. — The  results  in  these  cases  appear  to  be 
less  satisfactory  than  in  either  of  the  others,  and  failures  are  often  seen  in  Enghsh 
hospital  practice  after  operations  by  the  older  methods.  Of  86  cases  followed 
through  by  Pott,  54-7  per  cent  were  cured,  but  nearly  half  relapsed.  Capelle's 
figures  for  35  cases  are  rather  better.  Probably  the  newer  methods,  the 
fihgree  operation  and  the  transverse  line  of  suturing,  will  show  improvement  on 
these  results.  At  the  Bristol  Royal  Infirmary,  of  9  cases  of  umbihcal  hernia 
followed  eighteen  months  to  four  years,  5  were  cured  and  4  relapsed. 


HERNIA,     STRANGULATED  215 

References. — Pott,  Deut.  zeit.  f.  Chir.  1903,  Ixx  ;  Bull  and  Coley,  Jour.  Amer. 
Med.  Assoc.  1907,  xlix,  ioi7;  Kellock,  Proc.  Roy.  Soc.  Med.  1912,  pt.  iii.,  surg.  sect., 
26  ;  Simmonds,  Boston  Med.  and  Surg.  Jour,  igio,  clxii,  847  ;  Capelle,  Beitr.  z,  klin. 
Chir.  1909,  Ixiii,  264  ;   Fagge,  Proc.  Roy.  Soc.  Med.  1911,  surg.  sect.,  165. 

A.  Rendle  Short. 

HERNIA,  STRANGULATED.— If  we  use  the  term  in  its  strict  sense,  excluding 
cases  in  which  the  herniated  loop  of  bowel  is  merely  obstructed  by  fasces,  strangu- 
lated hernia,  apart  from  treatment,  is  practically  a  death-warrant.  It  would  be 
impossible  nowadays  to  obtain  figures  showing  in  how  many  patients  the  hernia 
would  discharge  its  contents  through  the  skin,  and  so  save  life  at  the  expense  of 
a  fascal  fistula.  In  the  great  majority  of  cases  in  which  this  happens,  death 
nevertheless  supervenes,  and  until  this  release  occurs  the  patient's  condition  is 
most  pitiable,  on  account  of  burrowing  abscesses  and  very  violent  and  extensive 
dermatitis  set  up  by  the  irritation  of  the  contents  of  the  small  intestine.  The 
percentage  of  spontaneous  cures  in  cases  of  strangulated  hernia  is  said  to  be 
about  2  per  cent  (Coley,  in  Keen's  Surgery). 

Gangrene  of  the  Gut. — The  occurrence  of  this  complication  depends  upon 
three  factors  :  the  tightness  of  the  constriction,  the  length  of  time  that  the  hernia 
has  been  strangulated,  and  the  situation.  In  a  series  observed  during  five 
years  at  St.  Thomas's  Hospital,  Corner  found  gangrene  in  4  per  cent  of  the 
inguinal,  10  per  cent  of  the  femoral,  and  25  per  cent  of  the  cases  of  strangulated 
umbilical  hernia.  Usually  it  takes  about  three  days  to  develop  ;  there  are, 
however,  very  many  recorded  instances  in  which  gangrene  has  supervened  in  a 
day.  Out  of  119  cases  of  strangulated  hernia  at  the  Bristol  Royal  Infirmary, 
2  had  become  gangrenous  in  less  than  twenty-four  hours,  and  i  in  less  than 
twelve  hours  ;  there  is  a  case  in  the  literature  which  gangrened  in  four  hours. 
Of  course,  gangrene  makes  the  prognosis  as  to  life  much  graver. 

Duration  of  Life  and  Cause  of  Deatti. — Apart  from  operation,  the  average 
duration  of  life,  according  to  old  figures  supplied  by  Macready,  is  about  seven 
to  ten  days.  It  may  be  much  shorter  ;  there  are  many  recorded  instances  of  a 
fatal  issue  within  twenty-four  hours,  and  two  have  been  known  to  die  within  a 
couple  of  hours. 

The  cause  of  death  is  usually  peritonitis  ;  next  to  this,  profound  toxaemia. 
Others  die  of  various  lung  complications,  either  from  inhalation  of  foul  vomit,  or 
from  embolic  pyaemia. 

Treatment  by  Taxis. — In  the  days  of  pre-antiseptic  surgery,  prolonged  and 
vigorous  taxis  was  employed  in  almost  all  cases.  Of  course  it  frequently  failed, 
and  recovery  by  no  means  always  took  place  even  when  it  succeeded  in  reducing 
the  hernia.  Thus,  according  to  Frickhoffer  (1861),  of  300  cases  of  strangulated 
femoral  hernia  reduced  by  taxis,  14-9  per  cent  died,  and  of  518  cases  of  strangu- 
lated inguinal  hernia,  7-8  per  cent  died.  The  deaths  were  due  to  reduction 
of  gangrenous  gut,  rupture  of  the  gut,  reduction  en  masse  (or  reduction  into 
another  sac),  pre-existing  peritonitis,  or  paralysis  of  the  bowel. 

Nowadays,  taxis  is  only  employed  with  gentleness,  and  for  a  few  minutes,  in 
early  cases  ;  in  late  cases,  it  is  usually  possible  to  tell  almost  immediately  by  the 
feel  that  taxis  would  be  hopeless.  Probably,  if  seen  within  a  few  hours,  the 
majority  of  strangulated  inguinal  or  umbilical  hernias,  if  previously  reducible, 
could  be  safely  treated  by  taxis,  though  of  course  a  subsequent  radical  cure 
would  be  desirable. 

In  young  children,  the  writer  has  had  considerable  success  in  getting  back  a 
hernia  strangulated  less  than  twelve  hours  by  tying  the  child  in  bed  in  an  inverted 
position  and  giving  chloral.  This  is  often  valuable,  as  it  allows  an  immediate 
operation  to  be  converted  into  a  routine  one. 


2l6 


INDEX    OF    PROGNOSIS 


Used  only  in  early  cases,  for  a  short  time,  and  with  a  light  hand,  taxis  is  not 
likely  to  cause  any  damage,  and  if  the  bowel  can  be  returned  the  patient  will 
almost  certainly  get  well.  I  have  seen  profuse  bloody  diarrhoea  follow.  Of 
24  cases  reduced  by  taxis  at  the  Bristol  Royal  Infirmary  since  1900,  every  one 
recovered. 

Treatment  by  Operation. — One  of  the  oldest  of  surgical  operations,  herniotomy 
for  strangulated  hernia  has  improved  immensely  in  its  results  of  late  years. 

Between  1836  and  1841,  of  183  herniotomies  in  Paris,  62'2  per  cent  died. 

Between  1869  and  1888,  of  283  herniotomies  for  strangulated  inguinal  hernia 
in  four  London  hospitals,  59  per  cent  died. 

At  the  present  time,  the  results  may  be  gathered  from  the  following  table  : — • 


Results  of  Operation  for  Strangulated  Hernia. 


INGUINAI. 

Femoral. 

Umbilical 

Obiueatok 

Hospital 

CaseB 

Died 

Per 
cent 

Cases 

Died 

Per 
cent 

Cases 

Died 

Per 
cent 

Cases 

Died 

Per 
cent 

St.  Thomas's,  1  1907 

to  1911 
Middlesex,  2  1907  to 

1911  - 

Bristol    Royal    In- 
firmary,   1900  to 

1912  - 

111 

37 
119 

21 

8 

22 

— 

103 
29 

96 

24 
3 

14 



30 
11 

11 

14 

2 

2 

— 

2 
3 

0 

0 
3 

— 

Total       - 

267 

51 

19 

228 

41 

18 

52 

18 

34-5 

5 

3 

60 

It  will  be  observed  that  the  mortality  for  inguinal  and  femoral  hernia  is 
approximately  the  same,  a  little  under  20  per  cent ;  that  umbilical  hernia  is 
decidedly  worse,  and  that  in  the  majority  of  obturator  hernias  the  patients  die. 

This  agrees  well  with  the  experience  of  seven  German  writers  quoted  by 
Meyer^  ;  out  of  1429  cases  of  various  hernise  strangulated,  20-7  per  cent  died  ; 
in  56  cases  of  obturator  hernia,  Meyer  reports  32  deaths,  that  is,  57  per  cent. 

We  have  next  to  consider  the  results  of  operation  under  certain  special 
conditions. 

The  Age  of  the  Patient. — All  writers  agree  that  the  prognosis  is  much  more 
grave  in  elderly  persons.  Children  usually  do  well.  According  to  Collins,*  the 
mortality  in  1902  was  23  per  cent,  but  it  is  now  3  to  10  per  cent,  given  early  inter- 
ference. Of  12  cases  in  infants  under  two  years  of  age  treated  by  operation 
at  the  Bristol  Royal  Infirmary,  every  one  recovered. 

The  Time  of  Operation. — It  is  no  doubt  true,  in  the  main,  that  good  results 
depend  on  early  operation.     Macread}?^^  calculates  from  129  cases  :- — 


Operation  within  24  hours 
,>  24-48       „ 

48-72       „ 
„  after     72       ,, 


12-5 
26-1 

36-3 

44 


per    cent    died 


It  is  a  remarkable  fact,  however,  in  the  figures  of  the  Bristol  Royal  Infirmary, 
that  the  correspondence  is  b]/-  no  means  so  close  as  might  have  been  expected. 
After  three  or  more  days  of  strangulation,  55  cases  (25  inguinal,  30  femoral)  were 
operated  on  ;  of  these,  9  died,  that  is,  16  per  cent,  or  positively  fewer  than  those 
operated  on  early  !     It  would  be  most  calamitous,  of  course,  to  use  this  as  an 


HEART,     CHRONIC     VALVULAR    DISEASE     OF  217 

argument  for  delay.  The  truth  of  the  matter  is  that  cases  with  marked  sym- 
13toms  are  Ukely  to  obtain  help  and  get  treated  early,  whereas  there  is  a  type 
of  strangulation  which  comes  on  more  quietly  and  is  not  so  rapidly  fatal. 

The  best  results,  of  course,  were  obtained  by  operation  within  twenty-four  hours. 
Of  88  such  cases  at  the  Bristol  Royal  Infirmary  (femoral  and  inguinal),  only  7  died, 
that  is,  8  per  cent,  instead  of  the  general  average  of  nearly  20  per  cent.  These 
7  cases  mostly  showed  gangrenous  gut,  and  some  of  them  were  very  aged. 

The  Various  Methods  of  dealing  ivith  Gangrenous  Gut. — When  gangrenous  gut 
is  found  at  operation,  two  courses  are  open.  We  may  either  resect  the  loop, 
including  any  dilated  paralyzed  coils  on  its  proximal  side,  or  we  may  content 
ourselves  with  making  an  artificial  anus.  From  a  study  of  the  literature  and 
hospital  records,  Hesse*'  gives  the  results  as  follows  : — 


Operation 

Cases 

Died 

Per  cent 

Artificial  anus 
Resection  of  loop 

604 
860 

382 

71-3 
44'3 

It  must  not  be  concluded  from  these  figures,  however,  that  resection  is 
invariably  the  best  treatment.  No  doubt  the  higher  mortality  is  partly  due  to 
the  fact  that  the  very  worst  cases  were  treated  by  making  an  artificial  anus. 
Like  all  hterature  figures,  the  results  are  probably  shown  in  an  unduly  favourable 
light,  owing  to  the  pubhcation  of  successes  and  suppression  of  failures. 

Of  30  cases  recently  seen  at  St.  Thomas'  HospitaP  : — 

18  were  treated  by  resection  ;    8  cured,  10  died. 

10  ,,  enterostomy  ;    1  cured,     9  died. 

2  ,,  invagination ;    2  cured,     0  died. 

Prognosis  in  Individual  Cases. — Before  operation,  the  principal  guides  to  an 
accurate  prognosis  are  the  age  of  the  patient,  the  degree  of  collapse,  and  especially 
the  nature  of  the  vomit.  If  the  latter  consists  of  foul  jejunal  contents,  the 
outlook  is  grave  ;  if  it  is  definitely  fsecal  in  odour,  the  patient  is  nearly  always 
doomed.  Evidence  of  peritonitis  makes  an  almost  hopeless  prognosis  ;  so  does 
a  sense  of  rupture  with  sudden  cessation  of  the  pain. 

At  operation,  a  Richter's  hernia  makes  for  a  rather  worse  prognosis  ;  and,  of 
course,  the  presence  of  gangrene  is  very  ominous.  Meyer  reports  252  German 
cases  in  which  gangrene  was  found ;  the  death-rate  in  various  statistics  was 
from  50  to  85  per  cent. 

After  operation,  persistent  vomiting  is  a  grave  sign  ;  it  may  mean  paralysis 
of  the  gut.  Som.etimes  washing  out  the  stomach  may  give  great  relief  if  the 
vomiting  is  only  due  to  jejunal  contents  therein.  Pituitary  extract,  physo- 
stigmine,  salines,  or  hormonal  may  overcome  the  paralysis  of  the  loop  of  bowel. 

As  already  stated,  strangulated  umbilical  hernia  is  worse  than  femoral  or 
inguinal,  partly  because  the  patient  is  likely  to  be  old,  fat,  or  bronchitic,  and  also 
because  there  is  a  tendency  to  consider  it  as  merely  obstructed,  and  so  to  delay 
treatment.  Strangulated  obturator  hernia  is  dangerous  because  it  is  often 
diagnosed  late. 

References. —  ^St.  Thomas's. Hasp.  Rep.  ;  'Middlesex  Hasp.  Rep.  ;  ^Meyer,  Arch, 
f.  klin.  Chir.  IQ14,  ciii.  497;  ^Collins,  Ann.  Surg.  1913,  Ivii,  188;  ^Macready,  Treatise 
on  Ruptures  ;   ^Hesse,  Beit.  z.  klin.   Chir.  1907,  iv,  i  ;   'Corner,  Lancet,  igoS,   i,   1692. 

A.  Rcndle  Short. 

HEART-BLOCK. — {See  Pulse,  Irregularities  of  the.) 

HEART,  CHRONIC  VALVULAR  DISEASE  OF— The  outlook  in  chronic 
valvular  disease  is  notoriously  obscure,  and  the  new  light  which  is  breaking  in 
hardly  warrants  didactic   statements.     Recent  work  teaches  us  that   it  is  a 


2i8  INDEX    OF    PROGNOSIS 

misconception  to  regard  a  lesion  of  the  valves  as  constituting  a  true  morbid 
entity.  The  three  great  causes  of  valvular  disease — rheumatic  infection, 
syphilis,  and  atheroma — whenever  they  injure  the  valves,  damage  the  even 
more  important  myocardium  at  the  same  time.  In  a  few  years  from  now  we 
shall  speak  of  cardiac  rheumatism  or  cardiac  syphihs  as  the  disease,  and 
mitral  obstruction  and  aortic  insufficiency  as  symptoms,  or  at  most  phases, 
of  those  diseases.  A  book  of  this  kind  is,  however,  not  the  place  for  intro- 
ducing a  sweeping  change  of  terminology,  and  the  more  usual  plan  of  dividing 
valvular  diseases  along  anatomical  hnes  \^ill  be  followed.  Even  so,  however, 
it  soon  proves  impossible  to  exclude  etiological  considerations. 

Mitral  Regurgitation,  for  instance,  is  notoriously  a  symptom  which  it  is 
customary  to  treat  of  as  if  it  were  a  disease.  The  available  evidence  teaches 
that  generally,  if  not  always,  it  is  myocardial  and  not  endocardial  disease 
that  makes  the  mitral  valve  incompetent.  Stiffening  of  the  mitral  cusps  causes 
obstruction,  not  incompetence ;  myocardial  disease  promotes  stretching  of  the 
mitral  ring  to  the  point  at  which  it  becomes  incompetent.  The  course  of  the 
mitral  defect  is  therefore  in  the  main  that  of  the  myocardial  lesion  that  is 
responsible  for  it. 

The  diagnosis  of  mitral  incompetence  rests  on  the  presence  of  a  sj^stohc  bruit 
at  the  apex,  providing  the  possibihty  of  the  latter  ha\dng  an  exocardiac  origin 
has  been  excluded.  What  does  the  discovery  of  this  murmur  portend  ?  As 
we  have  already  seen,  mitral  regurgitation  is  one  result  of  myocardial  atony  ; 
with  one  important  exception,  to  be  mentioned  presently,  this  is  its  whole 
significance.  Clearly,  then,  we  have  first  to  ask  ourselves  what  is  the  morbid 
process  that  is  injmring  the  muscular  walls  of  the  heart  and  making  them  atonic. 
In  many  cases  it  is,  of  course,  some  temporary  anaemia  or  toxeemia  of  the  whole 
economy,  such  as  chlorosis  or  pernicious  anaemia  on  the  one  hand,  or  diphtheria 
or  typhoid  fever  on  the  other,  that  is  attacking  the  myocardium  among  other 
organs.  Here  the  prognostic  import  of  mitral  incompetency  is  small ;  since  it 
furnishes  some  proof  that  the  heart  is  attacked,  it  cannot  be  said  to  have  no 
importance  whatever ;  but  the  fact  that  there  is  a  mitral  systohc  murmur  adds 
nothing  at  all  to  the  gravitj^  of  the  prognosis.  If  in  diseases  of  this  general 
kind  the  patient's  death  is  to  be  through  his  heart,  it  ^^dll  not  be  because  the 
mitral  ring  is  so  weakened  that  the  valve  leaks  ;  it  ^^•ill  be  because  the  more 
important  function  of  contractility  is  impaired,  and  experience  teaches  that 
atony  of  the  mitral  ring,  as  revealed  by  the  mitral  regurgitant  murmur,  is  no 
index  at  all  of  interference  with  contractility. 

When  we  come  to  those  diseases  in  which  the  heart  is  picked  out  for  attack 
by  the  morbid  process  (syphihs,  alcohohsm.,  arteriosclerosis) — processes,  too, 
which  last  till  and  tend  towards  death — a  little  more  weight  attaches  to  the 
presence  of  mitral  incompetence.  As  in  the  group  of  conditions  considered  above, 
it  is  one  more  proof  of  the  fact  that  the  heart  is  really  injured.  But  a  greater 
importance  than  this  is  often  claimed  for  the  mitral  regurgitant  murmur.  It  is 
said — Here  is  a  heart  that  from  now  onwards  has  to  bear  the  disadvantages 
of  a  mitral  valve  that  does  not  allow  the  left  auricle  and  its  tributary  pulmonary 
veins  to  be  drained.  These  drawbacks  are  alleged  to  be  imperfect  aeration 
of  the  blood  that  is  passing  through  the  lesser  circuit,  and  extra  work  for  the 
right  heart.  These  ideas  are  worth  considering  :  if,  in  a  case  of  chronic  myo- 
cardial disease  belonging  to  any  of  the  types  named  above,  there  be  found  a 
mitral  regurgitant  murmur,  it  does  imply  some  liability  to  pulmonary  stasis  ; 
and  if  the  second  sound  at  the  pulmonic  cartilage  be  accentuated,  this  hability 
is  probably  being  incurred.  In  fact,  it  is  not  too  much  to  say  that  the  best  way 
of  measuring  the  amount  of  stress  imposed  on  the  lesser  circuit  by  mitral  leakage 


HEART,     CHRONIC     VALVULAR    DISEASE     OF  219 

is  by  observation  of  the  degree  of  accentuation  of  the  puhnonary  second  sound. 
Over  against  the  evils  attendant  on  the  mitral  defect  in  such  a  case  there  are, 
on  the  other  hand,  certain  considerations  which  suggest  that  the  supervention 
of  mitral  regurgitation  may  give  actual  relief  where,  as  in  many  cases  of  chronic 
myocardial  disease,  the  contractile  power  of  the  left  ventricle  seems  to  be  giving 
out.  Under  such  circumstances  the  fact  that  a  little  blood  leaks  back  into  the 
left  auricle  is  no  doubt  bad  for  the  pulmonary  system  ;  but  the  harm  done  in 
this  way  is  outweighed  by  the  relief  afforded  to  the  wearing-out  ventricle,  in 
that  its  systolic  task  is  a  little  lightened.  Therefore  one  need  not  be  perturbed 
because  a  cardiosclerotic  with  angina  and  breathlessness  develops  a  mitral 
systolic  bruit ;  it  is  quite  likely  that  relief  from  pain  and  other  symptoms  may 
follow.  In  all  such  cases  as  these,  the  prognosis  is  really  that  of  the  disease 
itself  ;   the  mitral  leak  is  but  one,  and  by  no  means  the  most  important,  feature. 

We  said  above  that,  with  one  reservation,  mitral  regurgitation  is  an  expression 
of  myocardial  atony  and  no  more.  This  one  reservation  has  to  be  made  in 
regard  to  mitral  disease  due  to  rheumatism  of  the  heart.  Here  the  mitral 
apparatus  is  doubly  afflicted  ;  the  myocardial  lesions,  which  always  occur  in 
every  case  of  active  carditis,  and  often  persist  when  the  acute  phenomena  have 
died  down,  favour  stretching  of  the  ring,  while  in  practically  every  case  each 
of  the  recurring  phases  of  active  infection  adds  something  to  the  inflamma- 
tory fibrosis  of  the  mitral  curtains — a  fibrosis  which,  once  established,  never 
disappears.  The  active  phases  are  more  or  less  limited  to  the  first  twenty  years 
of  life  ;  the  lesions  of  the  valves  and  pericardium  that  are  established  during 
these  years  remain,  while  the  myocardial  lesions  recover  to  a  variable  degree. 

So  far  as  the  mitral  regurgitant  bruit  is  concerned,  then,  we  have  to  find  out 
to  what  extent  it  points  to  muscular  damage  that  will  pass  away,  and  to  what 
extent  to  valvular  fibrosis  that  will  tend  to  get  worse.  In  the  writer's  view, 
the  myocardial  factor  in  rheumatic  mitral  incompetence  is  far  more  important 
than  the  endocardial  ;  this  view  is  chiefly  based  on  post-mortem  evidence. 
It  is,  however,  probable  that  the  more  stiffened  the  mitral  curtains,  the  louder 
and  harsher  the  mitral  murmur.  It  is  further  true  that  the  presence  and  per- 
sistence of  this  murmur  are  evidence  of  the  presence  and  persistence  of  organic 
disease  of  the  heart.  Kemp's  recent  inquiry  into  the  subsequent  course  of  the 
cardiac  complications  of  acute  rheumatism  shows  that  the  mitral  systolic  bruit 
which  is  so  prominent  a  characteristic  of  such  attacks  disappears  during  or  after 
convalescence  in  about  one-third  of  the  cases.  The  writer's  experience  is  roughly 
confirmatory  of  this  ;  but  it  also  shows  that  a  bruit  which  has  persisted  for  a 
year  after  it  was  first  established  is  not  likely  to  clear  up.  The  great  hindrances 
to  the  disappearance  of  this  bruit  are  recurrent  attacks  of  rheumatic  carditis 
(in  children,  so  often  overlooked  at  the  time)  and  inadequate  care  after  obvious 
attacks  have  occurred.  The  latter  point  is  responsible  for  the  very  definite 
contrast  that  exists  between  the  behaviour  of  the  convalescent  rheumatic  heart 
in  children  of  the  hospital  class  and  in  those  who  are  more  happily  circumstanced. 
The  former  point  is  probably  responsible  for  the  fact  that  in  adults,  whose 
attacks  of  rheumatism  are  more  likely  to  be  articular  than  in  children,  and  who 
are  less  liable  to  relapse,  a  permanent  systolic  murmur  is  not  such  a  common 
feature  as  it  is  in  the  rheumatic  child.  Even  in  cases  where  the  apical  sj^stolic 
bruit  has  disappeared,  it  is  well  to  remember  that  the  patient  is  not  yet  out  of 
the  wood.  Either  with  or  without  obvious  relapse,  it  may  reappear,  or  a 
presystolic  murmur  may  develop.  Prolonged  absence  of  all  signs  of  mitral 
regurgitation  does  not  prove  that  the  mitral  curtains  are  normal  ;  a  process  of 
inflammatory  sclerosis  may  be  going  forward  through  a  stage  of  latency  to  the 
point  at  which  it  causes  signs  of  obstruction. 


INDEX    OF    PROGNOSIS 


As  for  the  actual  harm  which  mitral  regurgitation  of  rheumatic  origin  does 
to  the  rest  of  the  heart,  this  is  slight  compared  with  the  other  lesions  of  the  heart 
which  are  present  in  any  case  of  rheumatic  heart  disease  with  signs  of  mitral 
reflux.  It  is  true  that  in  these  cases  the  pulmonic  second  sound  is  nearly  always 
unusually  emphatic,  but  this  must  not  be  ascribed  solely  to  the  effect  of  mitral 
insufficiency  in  raising  the  tension  in  the  lesser  circuit ;  the  fact  that  the  conus 
arteriosus  dexter  is  uncovered  is  of  equal  importance,  as  it  brings  the  diastohc 
snap  of  the  pulmonary  valves  nearer  to  the  observer.  The  importance  of  the 
signs  of  mitral  leakage  is  indirect  ;  their  presence  proves  that  the  heart  has  been 
injured  by  the  rheumatic  infection,  and  their  persistence  proves  that  those  injuries 
have  not  disappeared,  and  that  there  is  still  a  hkehhood  of  permanent  cardiac 
disablement.  The  harsher  the  murmur,  the  greater  the  probability  of  this 
persistent  type  of  disease  ;  but  even  in  those  cases  where  a  loud,  harsh  systohc 
murmur  at  the  apex  persists  into  adult  life,  it  is  of  more  importance  to  note  the 
size  of  the  ventricles  and  to  estimate  their  functional  efficiency  than  to  bother 
oneself  unduly  about  the  intensity  and  line  of  spread  of  the  apical  bruit. 

To  sum  up  :  Mitral  regurgitation  is  a  symptom  of  various  disorders  and 
diseases  of  the  heart,  and  not  a  disease  of  itself.  Its  prognostic  significance  lies 
in  the  light  which  it  throws  on  the  course  of  the  underlying  condition. 

Mitral  Stenosis,  on  the  other  hand,  is  a  distinct  clinical  and  pathological 
entity.  The  cases  that  usually  bear  this  label  are  in  reality  cases  of  rheumatic 
heart  disease  that  have  escaped  the  earlier  dangers  of  the  disease  and  its  compli- 
cations, and  have  survived  into  the  residual  or  terminal  stage.  There  are  certain 
fundamental  facts  on  a  realization  of  which  prognosis  must  rest. 

1.  Recovery  is  impossible.  The  fibrotic  deformity  of  the  curtains,  the  essential 
fact  of  the  disease,  cannot  be  caused  to  disappear  by  any  means  in  our  power. 
As  they  are,  so  they  will  remain  to  the  end.  Prognosis  is  therefore  concerned 
solely  with  questions  as  to  the  patient's  chances  of  survival. 

2.  The  average  age  at  death  in  a  series  of  35  cases  of  pure  mitral  stenosis 
examined  post  mortem  at  the  Bristol  General  Hospital  was  39-2.  Probably  this 
figure  is  low  :  an  undue  proportion  of  patients  with  acute  reinfection,  as  well  as 
of  those  exposed  to  abnormal  stress,  is  sure  to  be  included  in  a  hospital  series. 
In  6  cases  there  was  evidence  of  recent  rheumatic  inflammation  of  the  heart 
in  addition  to  the  mitral  stenosis  ;  in  this  series  the  average  age  at  death  was  30 , 
while  in  8  cases  in  which  the  scarred  mitral  valves  had  become  the  seat  of  an 
ulcerative  endocarditis  the  average  age  at  death  was  31.  The  average  age  in 
the  first  class  would  probably  be  lower  if  one  were  able  to  include  those  cases 
in  which  fresh  rheumatic  infection  has  occurred  but  without  producing  any  gross 
naked-eye  change.  In  such,  microscopical  examination  discovers  signs  of  acute 
myocarditis.  Post-mortem  data  therefore  show  that  (a)  Mitral  stenosis  shortens 
life  by  twenty  to  thirty  years  ;  {b)  The  mechanical  effects  of  the  lesion  are 
responsible  for  the  end  in  a  majority  of  cases  ;  (c)  Two  complications,  fresh 
rheumatic  infection  and  ulcerative  endocarditis,  occur  in  a  small  number, 
bringing  about  a  fatal  termination  earlier  by  a  decade  than  would  have  been 
the  case  otherwise. 

3.  The  average  age  of  the  onset  of  symptoms,  in  those  cases  where  it  has  been 
possible  to  inquire  into  this  rather  vague  point,  has  been  26.  From  this  it 
seems  that  the  average  expectation  of  life  from  the  onset  of  symptoms  is  about 
13  years.  The  actual  date  at  which  the  cardiac  lesion  is  first  established  cannot 
be  ascertained  in  a  vast  majority  of  cases.  The  rheumatic  process  is  so  insidious 
in  its  beginnings  that  these  usually  go  undetected.  It  is,  however,  certain,  from 
those  cases  that  can  be  studied  from  the  beginning,  that  the  foundations  of  the 
valvular  lesion  are  laid  in  nearly  every  instance  before  the  age  of  16. 


HEART,     CHRONIC     VALVULAR     DISEASE     OF  221 

4.  There  is,  then,  a  prodromal  stage  during  wliich  the  mitral  orifice  is  becoming 
narrowed.  How  can  this  narrowing  be  foretold  ?  In  any  given  case  of  rheumatic 
carditis  the  signs  most  distinctly  indicative  of  stiffening  of  the  mitral  cusps  are 
persistent  harshness  and  loudness  of  the  systolic  apical  murmur,  if  one  be  present  ; 
sharp  accentuation  of  the  first  sound  at  the  apex  ;  doubling  of  the  second  sound 
at  the  apex,  if  that  doubling  be  constant  and  definite ;  and  the  existence  of 
a  constant  mid-diastolic  bruit  at  the  apex.  If  these  phenomena  persist  for 
months,  uninfluenced  by  rest,  one  is  justified  in  most  instances  in  regarding  the 
case  as  on  the  road  to  mitral  stenosis. 

Once  established,  the  course  of  mitral  stenosis  is  towards  cardiac  failure. 
As  we  have  seen,  this  end  may  be  forestalled  by  other  happenings.  The  sclerosed, 
vascularized  valve  may  become  the  home  of  other  organisms,  and  the  super- 
vention of  any  blood  infection,  such  as  pneumonia  or  puerperal  septicaemia,  is 
more  to  be  feared  in  the  subject  of  chronic  mitral  disease  than  in  others.  Actual 
evidences  of  ulcerative  endocarditis — swinging  temperature,  sweats,  petechije, 
wasting,  hsematuria,  and  so  on — should  never  be  forgotten  in  the  examination 
of  cases  of  chronic  mitral  obstruction.  If  signs  of  this  complication  are  found, 
the  outlook  is  well-nigh  hopeless ;  death  is  probable  within  the  year  {see 
Endocarditis,  Ulcerative).  The  supervention  of  a  fresh  attack  of  rheumatic 
carditis  is  not  so  immediately  dangerous.  In  the  presence  of  polyarthritis,  or 
chorea,  or  subcutaneous  nodes,  one  should  look  out  for  pericarditis,  dilatation 
of  the  heart,  or  fever  persisting  after  subsidence  of  the  outward  and  visible 
evidences  of  active  rheumatic  infection.  These  indicate  fresh  carditis,  inevitable 
results  of  which  are  temporary  impairment  of  the  myocardium  and  permanent 
addition  to  the  mitral  fibrosis.  For  these  two  reasons  rheumatic  reinfection 
of  the  patient  with  mitral  stenosis  must  always  be  regarded  with  respect ;  every 
such  attack  tends  to  shorten  the  patient's  life. 

One  other  accident  may  intervene  to  accelerate  the  patient's  gradual  progress 
to  the  grave — that  of  cerebral  embolism.  This  occurs  in  a  small  number  of 
cases  ;  Bradshaw  found  that  6  out  of  77  cases  of  mitral  stenosis  ended  so.  Apart 
from  the  symptoms  that  point  to  emboUsm  of  other  organs,  no  warning  is  given 
of  this  calamity.  It  rarely  occurs  except  in  persons  with  marked  evidence  of 
circulatory  embarrassment,  save  when  it  is  due  to  malignant  endocarditis 
engrafted  on  the  fibrotic  lesion.  The  presence  or  absence  of  symptoms  of  active 
infection  will  serve  to  distinguish  between  the  embolism  that  arises  from  thisl 
cause,  and  that  which  is  due  to  detachment  of  clot  from  the  mass  in  the  left 
auricle.  In  the  latter  case,  if  the  end  is  to  be  fatal  it  comes  at  once  ;  in  the 
former,  the  immediate  shock  of  the  embolism  may  pass  away,  and  yet  death 
may  follow  after  a  short  interval  from  the  later  effects  of  the  infection  of  the 
interior  of  the  skull  which  is  imphed  in  an  embolism  of  this  type.  In  either  case 
the  majority  of  cases  of  cerebral  embolism  compUcating  mitral  stenosis  do  not 
end  abruptly.  The  non-infective  embolus  that  fails  to  kill  establishes  a  hemi- 
plegia which  is  never  completely  recovered  from. 

In  a  large  majority  of  all  cases  of  mitral  stenosis  death  is  due  to  gradual  cardiac 
failure.  The  forces  responsible  for  this  are  two.  The  heart,  and  especially  the 
left  auricle,  is  asked  to  do  more  work  by  reason  of  the  valvular  obstruction  ;  and 
gradually  increasing  venous  stasis  undermines  the  nutrition  of  the  cardiac,  and 
particularly  the  auricular,  musculature.  An  unconquerable  vicious  circle  is 
thus  established.  The  results  are  pulmonary  engorgement,  auricular  breakdown, 
and  ultimate  ventricular  failure.  The  first  of  these  threatens  death  by  pre- 
disposing to  bronchitis,  suffocative  oedema,  and  multiple  infarction  of  the  lungs  ; 
and  for  these  reasons  dullness  at  the  bases,  signs  of  bronchial  and  alveolar 
catarrh,  and  haemoptysis  are  bad  features  of  the  case.     Auricular  failure  can 


INDEX    OF    PROGNOSIS 


only  kill  in  so  far  as  it  predisposes  to  the  other  fatal  factors  ;  that  it  lends  itself 
to  pulmonary  hyperjemia  is  obvious,  but  it  is  not  always  realized  how  much  the 
importance  of  auricular  breakdown  lies  in  its  capacity  for  vexing  the  ventricles. 
The  auricular  contraction  is  not  a  vital  function — the  circulation  can  go  on 
without  it,  for  ventricular  diastole  will  drain  the  auricles  ;  but  ventricular 
systole  must  go  on — for  if  it  stops,  life  stops  too.  Now,  auricular  failure 
contributes  to  the  ultimate  downfall  of  the  ventricular  function  in  two  ways. 
The  overworked,  underfed  auricle  goes  into  fibrillation  ;  instead  of  handing 
down  a  regular  series  of  stimuli  to  the  ventricle  at  the  rate  of,  say,  80  to  the 
minute,  it  pours  down  stimuli  into  the  ventricle  in  a  disorderly  and  incessant 
stream,  which  escape  into  the  latter  chamber  as  fast  as  the  auriculo-ventricular 
connections  will  transmit  them.  The  result  is  that  the  ventricle  is  stimulated 
to  contract  more  often  than  is  necessary,  and  in  so  disorderly  a  fashion  that 
contractile  substance  cannot  be  built  up  on  the  ordinary  rhythmic  plan — a  fact 
which  cannot  but  indicate  some  waste  of  energy.  -Left  auricular  asystole 
also  adds  directly  to  the  work  of  the  right  ventricle,  and  thus  increases  the 
probability  of  its  failure.  It  also  helps  to  overthrow  the  ventricular  functions 
by  increasing  venous  stasis,  and  so  damaging  the  nutrition  of  the  ventricular 
musculature. 

There  are  thus  three  things  to  take  note  of  if  we  are  seeking  to  ascertain  how 
near  the  patient  is  to  auricular,  and  thence  to  ventricular,  breakdown  :  (i)  Pitch 
of  stasis  ;   (2)  Condition  of  auricles  ;    (3)  Condition  of  ventricles. 

1.  Pitch  of  Stasis  is  to  be  measured  by  certain  sj^mptoms  :  dyspnoea  and 
cyanosis  afford  our  best  means  of  raeasuring  it  in  the  earlier  stages  ;  later 
we  may  be  guided  also  by  the  total  daily  output  of  urine,  the  presence  or 
absence  of  hepatic  enlargement,  the  size  of  the  veins  in  the  neck,  and  the 
occurrence  of  oedema  (though  this  is  quite  a  late  feature  of  mitral  stenosis). 

2.  The  Condition  of  the  Auricles  may  be  judged  from  data  bearing  on  (a)  their 
size,  (p)  their  functional  integrity. 

a.  Increase  in  the  size  of  the  auricles  is  a  bad  feature  of  mitral  stenosis  as  far 
as  it  goes,  but  it  matters  less  than  the  more  positive  and  direct  evidences  of 
impaired  function.  Dilatation  of  the  right  auricle  is  indicated  by  duUness 
filhng  in  the  cardio-hepatic  angle  ;  skiagraphy  is  also  of  service,  and  it  is  even 
more  so  in  the  examination  of  the  deep  and  inaccessible  left  auricle.  The 
pressure  signs  that  may  arise  from  extreme  dilatation  of  the  left  auricle  (left 
recurrent  laryngeal  palsy,  dysphagia,  etc.)  are  all  of  serious  prognostic  import. 

b.  The  signs  of  the  previous  class  are  less  frequent  and  less  ready  to  hand 
than  the  evidences  of  impaired  auricular  function.  By  far  the  most  important 
of  these  is  the  totally  irregular  pulse,  which  is  a  constant  feature  of  auricular 
fibrillation.  The  reasons  why  this  upset  of  rhythm  is  bad  for  the  heart's  working 
have  been  stated  above,  but  it  must  be  remembered  that  the  inception  of  this 
form  of  arrhythmia  marks  two  things  :  the  arrival  of  the  auricle  at  an  advanced 
stage  of  degeneration,  and  the  addition  of  a  new  disability  to  the  disadvantages 
under  which  the  ventricles  are  working.  In  26  cases  under  the  writer's  care  the 
average  age  at  which  this  form  of  arrhythmia  was  first  detected  was  about  forty, 
a  httle  in  excess,  that  is  to  say,  of  the  average  age  at  death  in  these  cases.  This 
proves  that  the  totally  irregular  pulse — or  rather,  the  fibrillation  which  underlies 
it — is  a  terminal  phase  in  those  cases  of  mitral  stenosis  that  have  escaped  the 
more  summary  modes  of  termination.  The  patient  may  hve  on  for  years,  if  he 
is  careful,  after  this  has  developed  ;  in  rare  instances  he  may  even  be  able  to  go 
to  work  and  lead  a  fairly  active  life  ;  but  it  will  be  on  condition  that  he  remains 
in  the  doctor's  hands  and  submits  to  his  advice  for  the  rest  of  his  days.  Total 
arrh^-thmia   nearly   always    marks   the    beginning   of   total    invalidism.     The 


HEART,     CHRONIC     VALVULAR    DISEASE     OF  223 

expectation  of  life  from  its  onset  varies  from  a  few  months  to  ten  years,  or  even 
longer  in  very  fortunate  cases,  the  average  expectation  being  about  five  years. 
The  factors  making  for  long  life  in  such  circumstances  are  a  good  ventricle  and 
a  quiet  life.  For  this  reason  older  persons  often  do  better  than  younger  ones  ; 
in  the  latter  the  irregular  pulse  begins  before  the  ventricle  has  had  time  to  recover 
from  the  direct  infective  injuries  of  the  first  two  decades,  and  moreover  they  are 
less  willing  to  go  softly  for  the  rest  of  their  days  than  are  those  who  have  reached 
years  of  discretion. 

The  other  evidences  of  auricular  failure  are  as  a  rule  masked  by  this  very 
striking  arrhythmia  ;  nevertheless,  they  may  be  found  if  they  are  looked  for, 
and  they  are  not  without  importance.  Decrease  in  intensity  of  a  previously 
loud  presystolic  murmur,  and  lessening  of  the  a  wave  as  compared  with  the  c 
wave  m  the  jugular  curve,  both  show  that  the  auricular  systole  is  becoming 
less  effective.  With  the  onset  of  total  arrhythmia,  both  murmur  and  a  wave 
disappear  entirely.  In  cases  of  mitral  stenosis  of  long  standing,  with  much 
dyspnoea  and  cyanosis,  the  appearance  of  many  auricular  extrasystoles  in  the 
pulse  curves  is  often  a  forewarning  of  imminent  fibrillation. 

3.  The  Condition  of  the  Ventricles. — Ventricular  failure  is  likely  to  occur 
earlier  in  patients  with  dilatation  of  the  ventricle,  in  those  who  have  chronic 
bronchitis,  in  persons  with  high  arterial  tension  (not  an  uncommon  accom- 
paniment of  mitral  stenosis),  and  in  those  who  are  prevented  from  giving 
themselves  a  due  amount  of  rest. 

The  last  phase  is  one  of  intense  hyperasmia  of  the  lungs,  with  or  without 
infarction  ;  to  this  stasis,  failure  of  vis  a  tergo,  as  well  as  increased  resistance  in 
front,  is  contributory.  Two  symptoms  that  may  appear  at  this  late  stage  are 
worthy  of  separate  mention  in  regard  to  prognosis — haemoptysis  and  vomiting. 
The  former  is  never  fatal  of  itself,  and  its  significance  differs  in  different  cases. 
There  is  a  constant  slight  weeping  from  the  lung  which  does  not  betoken 
dangerous  pulmonary  congestion  ;  it  comes  on  early  in  the  case,  and  may  continue 
intermittently  for  weeks.  There  is,  on  the  other  hand,  a  more  acute  and  intense 
type  of  haemoptysis  which,  if  accompanied  by  respiratory  embarrassment  and 
even  by  pain  in  the  chest,  points  to  the  occurrence  of  infarction.  This  is 
evidence  of  a  more  serious  state  of  affairs,  and  death  may  follow  soon.  But 
people  never  bleed  to  death  from  the  lungs  in  mitral  stenosis,  nor  do  they  drown 
in  their  own  blood  as  in  tuberculous  haemoptysis.  Vomiting  may  be  ceaseless 
and  intractable  in  this  last  stage  of  the  disease  ;   it  may  even  kill  the  patient. 

One  final  cause  of  death  in  mitral  stenosis,  rare  indeed  but  yet  worth  bearing 
in  mind,  is  cerebral  haemorrhage.  The  reason  lies  in  the  association  that  some- 
times exists  between  mitral  stenosis  and  granular  kidney,  and  the  consequent 
occasional  association  between  ixiitral  stenosis  and  high  tension.  It  is  a  rare 
coincidence,  yet  so  important  that  the  possibility  of  its  occurrence  should  not 
be  overlooked. 

The  risks  of  sudden  death  in  mitral  stenosis  are  small.  The  cerebral  lesions, 
embolism  and  haemorrhage,  are  possible  causes,  and  the  writer  has  known  at 
least  one  death  in  early  mitral  stenosis  which  occurred  without  warning. 
Possibly  this  was  due  to  recurrent  acute  carditis,  but  there  was  no  autopsj'. 
At  any  rate,  sudden  death  from  cardiac  failure  is  so  rare  in  mitral  stenosis  that 
patients  may  be  assured  that  the  risk  is  almost  non-existent. 

As  for  the  effect  of  treatment  on  the  prognosis,  the  most  conspicuous  benefit 
to  be  derived  is  that  which  those  enjoy  who  can  and  will  consent  to  limit  their 
activities.  With  regard  to  the  amount  of  activity  that  may  be  safely  allowed, 
there  is  of  course  no  fixed  rule  ;  but  the  patient  may,  if  he  must,  be  allowed  to 
undertake  such  work  as  does  not  cause  him  to  become  breathless.     The  writer 


224  INDEX     OF     PROGNOSIS 

has  under  observation  at  the  present  time  five  or  six  men  with  advanced  mitral 
stenosis  ;  one  is  employed  as  a  gardener,  another  intermittently  as  a  plasterer, 
a  third  as  a  tanyard  labourer,  and  so  on.  These  men  are  better  off  earning  a 
little  money  than  starving  in  idleness. 

Women  do  a  little  better  than  men,  and  if  their  circumstances  are  comfortable 
and  easy  they  do  better  than  those  who  are  compelled  by  want  of  help  to  do 
heavy  housework  and  to  undertake  personal  responsibility  for  large  families. 
Pregnancy  makes  the  symptoms  worse  for  the  time  being,  and  introduces  a 
small  risk  of  reawakening  of  the  rheumatic  infection.  French  and  Hicks  found 
that  in  only  28  per  cent  of  a  large  series  of  cases  of  mitral  stenosis  in  married 
women  was  there  any  direct  relation  between  pregnancy  and  heart  failure  ; 
and  in  nearly  all  of  these  it  took  several  pregnancies  to  bring  on  symptoms. 
It  is  only  in  extreme  cases  that  the  patient  has  to  be  prematurely  delivered  on 
account  of  the  aggravating  eifect  of  pregnancy  on  the  symptoms.  In  such  cases 
as  require  this  extreme  step,  its  consequences  are  often  disappointingly  small, 
the  patient  being  but  little  relieved ;  but  on  the  other  hand,  the  patient 
suffers  no  ill  consequences  from  the  strain  of  parturition,  whether  it  be  normal 
or  induced,  providing  it  be  not  unduly  protracted  ;  or  perhaps  it  would  be 
more  correct  to  say  that  the  ill-effects  of  that  strain  are  more  than  counter- 
balanced by  the  relief  afforded  by  the  emptying  of  the  uterus  and  the  removal 
of  the  impediment  to  breathing  which  the  fuU  uterus  offers.  In  French  and 
Hicks's  cases  there  was  no  single  example  of  death  during  labour,  and  in  only 
14  per  cent  of  those  whose  symptoms  of  heart  failure  began  during  pregnancy, 
did  the  woman  die  within  three  months  of  dehvery ;  and  the  percentage  of 
abortions  was  even  smaller  (5-5  per  cent). 

Of  other  points  regarding  treatment  in  its  effect  on  prognosis,  there  is  all  too 
little  to  be  said.  The  future  hope  in  mitral  stenosis  lies  in  prevention  and  not 
in  treatment.  One  observation  is  worth  attention — the  remarkable  benefit 
experienced  from  the  use  of  digitahs  by  patients  with  mitral  stenosis  and  total 
arrhythmia.  Armed  with  this  drug,  and  after  a  period  of  complete  rest,  patients 
recover  and  retain  their  capacity  for  work  in  a  most  gratifying  way.  If  this 
line  of  treatment — rest  and  digitalis — fails  in  a  week  to  slow  the  pulse  and  alleviate 
the  dyspnoea  and  other  symptoms,  in  a  case  of  mitral  stenosis  with  total 
arrhythmia,  the  patient  is  in  a  hopeless  case  and  cannot  survive  long.  If, 
however,  the  treatment  gives  relief,  it  is  probable  that  he  will  regain  to  some 
small  extent  his  capacity  for  getting  about  and  even  for  work  ;  though,  as  we 
have  already  remarked,  he  will  still  have  to  regard  himself  as  in  need  of  continued 
medical  care. 

Patients  who  are  urgently  dyspnoeic,  blue,  and  dropsical,  are  sometimes 
relieved  to  an  astonishing  extent  by  venesection,  a  procedure  which  seems  to 
give  cardiac  tonics  a  better  chance  of  helping  the  patient,  as  well  as  affording 
direct  rehef .  Leeching  may  have  a  similar  effect.  The  value  of  opium  in  giving 
the  patient  rest  may  also  be  mentioned. 

The  outlook  in  mitral  stenosis  is  discovered,  therefore,  by  assessing  its  effects 
on  the  functions  of  the  rest  of  the  circulatory  apparatus,  especially  the  left 
auricle  and  the  lesser  circulation. 

Aortic  Regurgitation  is  the  outcome  of  several  morbid  processes,  which  may 
act  together  but  much  more  often  operate  singly.  The  prognosis  varies  widely 
according  to  the  causation.  This  is  chiefly  because  different  causes  affect  the 
myocardium  in  varying  degree.  Syphilis  injures  it  profoundly  and  progressively  ; 
arteriosclerosis  as  progressively,  but  less  profoundly  and  rapidly  ;  rheumatism 
attacks  the  myocardium  severely,  but  for  the  most  part  its  effects  are  transient, 
though  liable  to  repetition.     The  prognosis  in  any  given  case  exhibiting  the 


HEART,     CHRONIC     VALVULAR     DISEASE     OF  225 

signs  and  symptoms  of  aortic  regurgitation  depends  also  on  the  degree  to  which 
the  valves  are  injured,  and  the  extent  of  the  secondary  effects  of  these  injuries 
on  the  general  efficiency  of  the  circulatory  apparatus. 

In  the  syphihtic  cases  the  expectation  of  life  from  the  onset  of  symptoms  is 
about  five  years,  if  we  exclude  cases  in  which  syphilitic  infection  of  the  aorta 
has  led  to  the  formation  of  an  aneurysm  as  well  as  to  valvular  disease.  In  cases 
of  the  latter  type  the  prognosis  is  even  worse. 

In  the  rheumatic  cases  the  prognosis  is  much  better.  This  is  not  seen  so  well 
in  mere  averages  of  duration  of  life  after  onset  of  symptoms  and  the  like,  as  in 
a  consideration  of  a  few  typical  cases.  Out  of  a  group  of  seven  fatal  cases  seen 
by  the  writer  in  recent  years,  the  youngest  died  at  13  in  an  acute  attack  of 
carditis,  in  which  the  aortic  lesions  had  little  or  no  effect  in  bringing  about  the 
fatal  issue  ;  while  the  oldest  was  a  man  of  45,  whose  ventricular  contractility 
had  been  failing  for  years.  Of  the  rest,  two  died  at  19  and  29  respectively, 
in  what  seemed  to  be  an  acute  phase  of  rheumatic  carditis  ;  two  others  at  35 
and  37  of  ventricular  failure,  and  the  fifth  at  29  of  malignant  endocarditis 
engrafted  on  the  old  valvular  lesion.  Thus  the  various  risks  of  rheumatic 
disease  of  the  aortic  valves  are  exemplified  :  acute  injury  of  the  myocardium  by 
recurrence  of  the  acute  infective  process,  progressive  ventricular  failure,  and 
ulcerative  endocarditis.  This  third  risk  is  of  course  much  less  often  encountered 
than  the  other  two,  so  that  those  who  are  fortunate  enough  to  escape  at  last  from 
the  years  in  which  the  rheumatic  infection  is  active,  and  who  are  also  able  in 
later  years  to  avoid  ventricular  overstrain,  may  look  forward  to  a  possibility 
of  long  life.  To  quote  examples,  the  writer  has  under  his  care  a  man  of  44  whose 
rheumatic  aortic  lesion  led  to  an  almost  complete  breakdown  seven  years  ago  ; 
warned  by  this,  he  exchanged  a  laborious  occupation  for  a  lighter  one,  and  is  at 
present  good  for  some  years  as  far  as  one  can  judge.  The  writer  also  knows 
two  members  of  the  profession  who  live  active  and  responsible  lives  in  spite  of 
rheumatic  aortic  incompetence  borne  in  each  case  for  a  number  of  years. 

A  third  ill-defined  group  consists  of  those  cases  in  which  the  aortic  incom- 
petence is  one  aspect  of  a  cardiosclerotic  process  of  the  senile  or  atheromatous 
type.  When  the  syphihtic  factor  has  been  rigorously  excluded,  this  class  is 
probably  a  small  one,  and  no  statistics  are  available.  Experience  shows, 
however,  that  the  course  is  slower  than  in  the  syphilitic  cases,  but  more  rapid 
than  the  rheumatic  ones  that  have  survived  into  the  fourth  and  fifth  decades. 

Turning  to  the  clinical  features  of  each  individual  case,  we  must  find  out,  first, 
how  badly  the  valves  leak,  and  secondly,  how  well  the  heart  bears  its  abnormal 
burden.  As  to  the  extent  of  valvular  injury,  the  direct  physical  signs  are  of 
less  value  than  those  which  point  to  the  effects  of  the  leak  on  the  peripheral 
circulation.  The  loudness  of  the  regurgitant  murmur  and  the  extent  of  the  area 
over  which  it  is  heard  teach  us  nothing  as  to  the  degree  to  which  the  valve  is 
rendered  incompetent  :  except  in  this  indirect  way,  that  if  the  bruit  be  heard 
loudest  at  or  above  the  aortic  cartilage  there  is  most  likely  some  dilatation  of 
the  aorta,  and  the  prognosis  is  worse,  since  dilatation  of  the  aorta  belongs  to  the 
cases  that  are  syphilitic  in  origin  or  severe  in  degree.  The  effect  of  the  leak  on 
the  peripheral  circulation  is  best  measured  by  observing  the  pulse-pressure — 
i.e.,  the  difference  between  the  systolic  and  the  diastolic  pressure.  For  the  sake 
of  accuracy  it  is  well  to  measure  this  with  the  sphygmomanometer  in  every  case  ; 
but  even  where  this  is  not  immediately  feasible,  a  rough  estimate  of  the  circulatory 
disability  may  be  arrived  at  by  noting  the  amount  of  visible  pulsation,  and 
especially  the  amount  of  visible  capillary  pulsation.  The  wider  the  swing 
between  maximal  (systohc)  and  minimal  (diastolic)  fiUing  of  the  peripheral 
vessels,  the  greater  the  amount  of  reflux  and  the  worse  the  prognosis.     A  similar 

15 


226  INDEX     OF    PROGNOSIS 

conclusion  is  to  be  drawn  from  the  prevalence  of  any  of  those  symptoms  (head- 
ache, dizziness,  nose-bleeding,  visual  disturbances,  etc.)  that  indicate  unsteadiness 
in  the  supply  of  blood  to  the  systemic  organs  ;  the  more  marked  these  are, 
the  worse  is  the  leak  and  the  graver  the  prognosis. 

Even  more  important  than  the  state  of  the  peripheral  circulation,  however, 
is  the  condition  of  the  rayocardium.  How  far  is  it  able  to  meet  this  very  direct 
and  very  considerable  task  that  is  thrust  upon  it  ?  Here  a  knowledge  of  the 
etiology  is  indispensable,  and  it  is  especially  important  to  ascertain  whether 
or  not  there  is  a  syphiUtic  factor.  A  search  for  evidences  of  cerebrospinal 
syphilis,  and  an  examination  of  the  blood  by  the  Wassermann  method,  should 
not  be  forgotten  here.  The  discovery  of  the  syphilitic  factor  makes  the  prognosis 
worse,  because  it  impUes  an  attack  on  the  myocardium  by  a  progressive  and 
practically  invincible  process.  If  the  case  be  one  of  rheumatic  disease  of  the 
aortic  valves,  the  most  serious  risk  to  which  the  myocardium  is  exposed  is  that 
of  re-invasion  by  the  rheumatic  process  ;  this  danger  becomes  less  with  advancing 
years,  and  after  the  age  of  thirty  it  is  remote.  Of  the  cardiosclerotic  cases 
nothing  need  be  said,  but  that  the  same  morbid  process  that  has  led  to  calci- 
fication of  the  aortic  valves  is  sure  to  interfere  more  or  less  with  the  nutrition 
of  the  cardiac  wall,  and  to  do  so,  though  slowly,  yet  progressively. 

Not  only  etiology,  but  also  symptomatology,  come  under  review  in  finding 
out  what  chance  the  left  ventricle  has  of  coping  with  the  extra  burden  thrown 
on  it  by  the  failure  of  the  aortic  valves.  In  this  form,  of  valvular  disease  the 
danger-signals  to  be  anticipated  are  those  phenomena  that  point  to  exhaustion 
of  ventricular  contractility.  There  are  three  factors  at  work,  the  combined 
eflEorts  of  which  are  sure  to  undermine  the  efficiency  of  the  ventricular  contrac- 
tions in  the  long  run  :  the  myocardial  lesions  of  the  causal  disease,  which  have 
just  been  discussed  ;  the  persistent  overstress  to  which  the  ventricle  is  exposed 
by  the  valvular  leak  ;  and  interference  with  the  myocardial  nutrition  by  the 
disturbance  in  the  peripheral  blood-supply,  which  tells  on  this  as  on  every  other 
systemic  tissue.  Failure  of  contractihty  is  therefore  probable  in  all  cases  except 
those  in  which  the  first  of  these  factors,  the  etiological  one,  has  done  its  worst 
in  early  life  and  become  inoperative  later — ^i.e.,  in  the  rheumatic  cases.  It  is 
for  this  reason  that  cardiac  pain,  dyspnoea,  and  cedema — all  of  them  evidences 
of  failing  contractile  force — are  of  more  significance  than  any  physical  signs 
in  aortic  disease  of  long  standing.  For  the  same  reason  the  alternating  pulse 
is  a  very  grave  sign  in  such  cases.  Among  the  physical  signs,  those  which  point 
to  progressive  increase  in  the  size  of  the  ventricle,  and  loss  of  strength  in  the 
first  sound  at  the  apex,  are  of  most  significance.  Anyttdng  suggestive  of  gross 
myocardial  change  (coronary  thrombosis  or  embolism,  rupture  of  the  heart, 
formation  of  a  cardiac  aneurysm)  is  of  course  of  almost  immediately  fatal  import. 
Rupture  of  a  valve,  on  the  other  hand,  though  it  adds  at  once  to  the  patient's 
discomforts  and  disabilities,  does  not  by  any  means  kill  at  once.  The  writer 
has  recently  seen  two  cases,  in  the  one  of  which  the  man  was  alive  and  at  work 
till  about  seven  years  after  the  rupture  seems  to  have  occurred,  while  in  the  other 
a  year  had  elapsed  and  the  patient  was  still  working.  The  opening  which  a 
sclerosed  valve  offers  to  the  various  organisms  capable  of  setting  up  an  ulcerative 
endocarditis  needs  not  to  be  enlarged  upon  ;  the  supervention  of  septicaemic 
symptoms  in  a  case  of  chronic  disease  of  the  aortic  cusps  will  readily  suggest 
the  appropriate  diagnosis  and  prognosis  [see  Ulcerative  Endocarditis).  The 
possibility  of  other  lethal  lesions  should  never  be  overlooked,  especially  in  the 
syphilitic  cases  (aneurysm,  cerebrospinal  syphihs). 

The  liability  to  sudden  death  of  persons  carrying  a  leaking  aortic  valve  is 
almost  proverbial.     Indeed,  this  risk  has  been  rather  over-emphasized.     Yet 


HEART,     CHRONIC     VALVULAR     DISEASE     OF  227 

when  we  consider  the  double  attack  to  which  the  ventricle  is  exposed  in  this 
form  of  valvular  disease — the  direct  injury  of  the  myocardium  that  is  inflicted 
by  that  which  causes  the  valvular  lesion,  and  the  less  direct  effects  of  overstrain 
resulting  from  the  incompetence  of  the  valve — it  is  not  to  be  wondered  at  that 
this  should  be,  above  all  others,  that  lesion  which  best  and  oftenest  exemplifies 
the  disastrous  effects  of  exhausted  ventricular  contractility.  In  the  syphilitic 
cases,  if  those  which  are  terminated  by  rupture  of  an  aneurysmal  sac  be  excluded, 
death  comes  suddenly  in  nearly  40  per  cent  ;  in  the  rheumatic  cases,  the  writer 
had  only  two  out  of  ten  fatalities  that  could  by  any  means  be  called  sudden. 
Syphilis  is  more  likely  to  cause  sudden  death  than  rheumatism,  because  of  its 
more  enduring  and  progressive  interference  with  the  nutrition  of  the  myocardium. 
In  many  of  the  cases  that  end  with  unexpected  abruptness,  this  catastrophe 
might  have  been  foreseen  and  possibly  averted  if  more  weight  had  been  given 
to  the  symptoms  of  faihng  contractility  that  were  present. 

As  for  the  effect  of  treatment,  the  results  of  antisyphilitic  measures  call  for 
brief  comment.  No  immediate  and  complete  cures  of  aortic  valvular  disease 
can  yet  be  placed  to  the  credit  of  salvarsan  ;  and  as  it  is  generally  acknowledged 
that  in  the  presence  of  cardiac  disease  the  use  of  this  medicament  is  not  entirely 
free  from  risk,  it  is  best  to  rely  on  mercury  and  iodide,  the  prolonged  use  of 
which  (and  especially  the  former)  does  indubitably  ameliorate  symptoms,  as 
much,  no  doubt,  by  its  action  on  the  myocardium  as  by  any  effect  on  the  valvular 
lesion  itself.  In  the  rheumatic  cases  the  estabhshment  of  a  quiet  way  of  life 
is  amply  justified  by  its  results. 

Complete  cure  is  excessively  unlikely,  but  it  does  occasionally  come  about. 
Signs  disappear,  and  symptoms  also.  Possibly  in  such  cases  dilatation  of  the 
aortic  ring  has  played  an  important  part  in  rendering  the  valve  incompetent, 
and  its  recovery  of  tone  has  restored  its  functional  integrity  to  the  valve.  It  is 
so  unlikely  and  so  unforeseeable  that  it  cannot  be  looked  for  with  any  confidence, 
but  the  fact  that  it  does  occur,  if  it  be  borne  in  mind,  will  serve  to  colour  one's 
view  of  the  disease. 

Lastly,  it  should  be  recollected  that,  in  spite  of  its  dangerous  nature,  in  spite 
of  the  variety  of  ways  in  which  it  may  end  life,  the  possession  of  an  incompetent 
aortic  valve  is  not  incompatible  with  a  long  life.  The  writer  has  already  given 
instances  of  this,  and  there  are  various  remarkable  examples  scattered  through 
the  literature  ;  one,  for  instance,  in  which  a  man  who  was  known  at  13  to  have 
aortic  valvular  disease,  was  still  carrying  it  with  comparative  comfort  and 
freedom  from  symptoms  at  66. 

Aortic  Stenosis  presents  three  classes  of  cases  to  be  considered.  The  first 
consists  of  those  patients  in  whom  the  obstruction  appears  to  develop  slowly, 
the  symptoms  being  first  noticed  at  or  about  the  age  of  30,  without  obvious 
cause,  apart  from  rheumatism  in  a  few  cases,  and  without  accompanying  signs  of 
aortic  regurgitation.  This  is  a  small  group  of  cases,  and  the  prognosis  is  nearly 
always  bad  ;  the  patient  rarely  passes  the  age  of  40.  In  a  second  group,  the 
patient  has  already  distinct  evidences  of  aortic  incompetence,  when  the  signs 
of  aortic  obstruction  become  superadded.  The  result  is  a  modification  of  the 
peripheral  phenomena;  the  pulse  loses  its  collapsing  character,  and  so  on. 
The  effect  on  the  prognosis  in  such  cases  is  not  as  bad  as  one  might  assume  at 
first  sight,  for  the  peripheral  effects  of  the  obstruction  neutralize  those  of  the 
regurgitation  to  some  extent.  Often  the  patient  is  actually  more  comfortable 
for  the  change.  It  is  only  in  cases  of  severe  valvular  change  that  this  sequence 
is  encountered,  so  that  the  regurgitation  is  generally  free  and  the  symptoms 
are  pronounced.  The  mitigation  of  the  symptoms,  which  ensues  upon  the  super- 
vention of  stenosis,  affords  the  patient  real  relief,  and  delivers  his  ventricle  from 


228  INDEX    OF    PROGNOSIS 

over-distention  in  diastole,  thus  diminishing  the  load  which  has  to  be  hfted 
by  each  systole  :  so  that,  for  the  time  at  least,  the  heart's  work  is  eased.  Of 
course,  the  ultimate  prognosis  is  not  good,  but  it  is  not  so  bad  as  in  the  first 
group.  In  the  third  group  are  collected  those  cases  of  stenosis  developing 
slowly  in  persons  of  50  or  over,  thanks  to  a  gradual  calcification  of  the  aortic 
cusps.  Here  the  morbid  process  is  a  very  slow  one,  and  though  the  coronary 
arteries  may  be  damaged  at  the  same  time,  the  myocardium  yields  but  slowly, 
and  the  patient  may  attain  to  old  age. 

In  individual  cases  of  aortic  stenosis  there  are  two  things  to  be  assessed — 
the  degree  of  obstruction  and  the  condition  of  the  left  ventricular  myocardium. 
The  former  is  determined  by  observation  of  the  type  of  pulse  rather  than  by  the 
physical  signs,  though  the  prominence  of  the  thrill  and  murmur  must  also  be 
given  some  weight.  The  more  characteristically  flattened  the  pulse-wave,  the 
worse  for  the  patient.  As  for  the  state  of  the  ventricular  muscle,  this  is  revealed 
by  an  examination  of  the  functions  ;  pain,  dyspnoea,  alternating  pulse,  and 
other  evidences  of  failing  contractility  are  ominous  signs. 

Treatment  has  little  effect,  even  in  the  syphilitic  cases. 

Combined  Aortic  and  Mitral  Valvular  Disease  is  encountered  in  two  sets  of 
cases.  In  the  first  the  rheumatic  inflammation  which  injured  the  one  set  of 
valves  did  the  same  by  the  other;  in  the  second,  ventricular  dilatation,  con- 
sequent on  aortic  insufficiency  and  diastolic  overfilling,  has  stretched  the  mitral 
ring  and  made  the  valve  incompetent.  In  the  first  class  of  case,  the  signs  of 
mitral  stenosis  are  added  to  indefinite  evidences  of  aortic  regurgitation  ;  or  it 
may  be  that  the  aortic  lesion  is  pronounced  and  the  mitral  signs  are  vague  ;  while 
in  a  few  there  are  pronounced  evidences  of  both.  In  any  such  case  the  gravity 
of  the  outlook  is  greater  than  in  the  presence  of  a  single  lesion,  partly  because 
the  mechanical  disabilities  of  the  one  lesion  are  added  to  those  of  the  other,  and 
partly  because  the  presence  of  severe  and  widespread  endocardial  lesions  in 
post-rheumatic  heart  disease  argues  the  presence  of  diffuse  and  severe  myocardial 
damage.  In  the  second  group  of  cases  the  supervention  of  mitral  incompetence 
in  an  aortic  case  is  evidence  of  severe  embarrassment  of  the  left  ventricle,  and 
therefore  of  bad  omen. 

Acquired  Lesions  of  the  Tricuspid  Valve. — The  prognosis  in  these  lesions  is 
based  on  the  fact  that  they  never  occur  alone. 

Tricuspid  Incompetence  is  so  common  that  some  writers  regard  it  as  one  of 
the  normal  functions  of  the  tricuspid  apparatus  to  open  but  under  stress  and 
relieve  a  distended  right  ventricle  by  permitting  a  certain  amount  of  back-flow 
into  the  distensible  liver  and  venous  system.  Whether  this  is  going  rather  far 
or  not,  evidence  does  not  at  present  allow  us  to  decide  ;  but  there  are  certain 
facts  available.  First,  such  diseases  as  mitral  stenosis,  cardiosclerosis,  and 
chronic  bronchitis  with  emphysema,  diseases  which  encourage  hyperaemia  and 
stasis  in  the  blood-channels  that  course  through  the  lungs,  lead  at  last  to  persistent 
over-stretching  of  the  right  auriculo-ventricular  communication  and  render  its 
valvular  apparatus  permanently  incompetent.  Second,  the  clinical  evidences 
of  this  persistent  incompetence  are  mainly  those  of  venous  stasis  in  the  sj^stemic 
circulation — big  veins  in  the  neck,  enlargement  of  the  liver,  diminution  in  the 
output  of  urine,  dropsy,  and  so  on.  Third,  the  more  pronounced  and  persistent 
these  symptoms,  the  worse  the  outlook  ;  partly  because  the  condition  of  venous 
stasis  thus  perpetuated  undermines  the  nutrition  and  efficiency  of  various  vital 
tissues,  the  myocardium  itself  among  them,  but  also  because  the  presence  of 
extreme  and  permanent  tricuspid  failure  proves  the  existence  of  a  proportionately 
severe  hindrance  to  the  drainage  of  the  lesser  circuit  into  the  left  heart.  The 
presence  or  absence  of  a  tricuspid  systolic  murmur  makes  little  or  no  difference 


HEART,     CHRONIC     VALVULAR     DISEASE    OF  229 

to  prognosis,  at  any  rate  as  compared  with  the  significance  of  the  symptoms 
mentioned.  In  the  first  place,  it  is  not  easy  to  decide  whether  or  no  the  bruit 
is  tricuspid  at  all ;  in  the  second,  the  valve  may  be  grossly  incompetent  without 
any  murmur  being  audible. 

Tricuspid  stenosis,  if  acquired,  is  always  the  outcome  of  rheumatic  carditis, 
and  as  such  is  little  more  than  an  unusual  feature  in  a  common  type  of  case. 
The  tricuspid  curtains  are  found  thickened  and  stift'ened  in  a  small  percentage 
of  cases  of  mitral  stenosis  coming  to  autopsy,  but  it  is  only  in  a  very  few  of  these 
that  the  presence  of  such  a  coincidence  of  lesions  can  be  diagnosed.  When  the 
diagnosis  can  be  made,  the  patient's  prospects  are  a  good  deal  worse  than  in  an 
uncomplicated  case  of  mitral  stenosis.  According  to  Newton  Pitt's  figures, 
the  duration  of  symptoms  does  not  usually  exceed  five  years,  and  about  half  the 
cases  fail  to  survive  the  age  of  30.  The  fiver  pulsation,  sufficiently  developed 
to  yield  a  clear  three-wave  phlebogram,  which  has  by  some  been  regarded  as  a 
sign  of  tricuspid  obstruction,  is  sometimes  encountered  apart  from  this  condition  ; 
but  even  so,  it  is  a  valuable  proof  of  advanced  engorgement  of  the  right  auricle, 
and  as  such  is  a  bad  sign. 

Acquired  Pulmonary  Lesions. — These  are  so  rare  that  they  may  be  quickly 
dismissed. 

Pulmonary  Stenosis  is  of  course  rarely  diagnosed  as  an  acquired  lesion  ;  it  runs 
a  short  course,  the  length  of  which  may  best  be  gauged  by  observation  of  the 
state  of  the  right  ventricle.  As  in  the  corresponding  congenital  malformation, 
the  patient  is  specially  liable  to  contract,  and  die  of,  phthisis. 

Pulmonary  Regurgitation,  due  to  inflammation  of  the  pulmonic  semilunar 
cusps,  is  a  very  rare  lesion  ;  the  diagnosis  is  a  bold  one,  but  if  it  has  been  made 
it  carries  with  it  a  bad  prognosis.  More  common  is  that  insufficiency  of  the 
pulmonary  valves  which  may  develop  in  advanced  mitral  stenosis  as  a  result  of 
the  great  rise  of  pressure  in  the  pulmonary  artery.  It  is  extremely  hard  in  many 
supposed  cases  of  this  condition  to  be  sure  that  we  are  not  deaUng  with  that 
very  frequent  result  of  rheumatic  carditis,  aortic  and  mitral  valvular  disease 
combined  ;  but  if  this  can  be  excluded  and  the  diagnosis  of  secondary  pulmonary 
insufficiency  substantiated,  it  may  be  regarded  as  a  bad  sign  in  a  case  of  mitral 
stenosis.  It  proves  the  existence  of  a  high  degree  of  circulatory  obstruction  ; 
and  it  also  threatens  overloading  of  the  right  ventricle.  As  a  matter  of  fact, 
its  prognostic  importance  is  not  as  great  as  inight  be  expected,  for  it  is  only  in 
cases  of  mitral  stenosis  that  are  obviously  advanced,  that  one  ventures  on  a 
diagnosis  of  secondary  pulmonary  regurgitation. 

In  conclusion,  the  general  principles  of  prognosis  in  chronic  valvular  disease 
may  be  briefly  re-stated. 

1.  The  valvular  lesion  is  but  a  part  of  the  picture  ;  it  is  the  observer's 
duty  to  discover  as  far  as  possible  the  state  of  the  whole  heart,  and  of 
all   the  organs. 

2.  The  outlook  depends  ultimately  on  the  balance  struck  between  valvular 
disability  and  myocardial  capacity.  To  what  extent  is  the  latter  capable  of 
rising  to  the  occasion  ? 

3.  This  question  is  best  answered,  speaking  generally,  by  an  intelligent 
exploration  of  the  symptoms,  and  a  search  for  evidences  of  myocardial  ex- 
haustion. 

4.  It  is  particularly  important  to  see  what  effect  a  period  of  rest  has  in  restoring 
myocardial  efflcicHcy  before  giving  an  unqualified  prognosis  in  an  apparently 
bad  case.  Carey  F.  Coombs. 


230  INDEX     OF     PROGNOSIS 

HEART,  CONGENITAL  MALFORMATIONS  OF.— In  forecasting  the  future 
of  a  child  or  young  adult  who  has  been  found  to  suffer  from  a  developmental 
fault  of  the  heart,  the  questions  that  have  to  be  answered  are.  How  long  is  he 
likely  to  live  ?  and  Is  there  any  chance  of  a  useful  career  for  him  ?  It  would 
be  possible  to  answer  both  of  these  questions  with  considerably  more  precision 
and  confidence  if  it  were  possible  in  every  case  to  discover  the  actual  nature 
of  the  malformation.  Unfortunately,  such  detailed  accuracy  is  out  of  reach 
in  very  many  cases,  so  that  one's  prognosis  is  founded  on  a  varying 
admixture  of  knowledge  of  the  defect  present  and  the  average  duration  of 
life  in  such  cases,  with  observation  of  the  symptoms  as  indices  of  the  extent 
to  which  the  efficient  working  of  the  heart  is  threatened  by  the  disabilities 
imposed  upon  it  by  the  errors  in  development. 

Average  Expectation  of  Life  in  various  Defects. — The  following  facts  and 
figures  are  collected  from  the  writings  of  Peacock,  Maude  Abbott,  and  others. 

The-  lesion  which  is  most  readily,  and  therefore  most  often,  diagnosed  is 
pulmonary  stenosis.  Patients  have  been  known  to  reach  a  good  age  with  this 
defect,  even  after  an  active  life.  The  writer  recalls  several  such — a  railway 
porter  who  at  twenty-three  was  just  beginning  to  be  dyspnoeic,  a  cook  who  at 
thirty-seven  showed  her  first  signs  of  broken  compensation,  and  a  lady  of  over 
forty  who  leads  a  fairly  active  life.  One  case  is  on  record  in  which  the  patient 
reached  the  age  of  fifty-two.  These,  however,  are  the  exceptions.  The  average 
age  at  death  in  pulmonary  stenosis  is  nine  and  in  pulmonary  atresia  three. 

The  co-existence  of  other  lesions  is  a  matter  of  some  weight.  Of  cases  in 
which  an  autopsy  has  been  made,  56  per  cent  of  those  in  which  there  was  no 
associated  defect  of  other  parts  of  the  heart  ended  fatally  within  the  first  two 
decades  of  life  ;  of  those  in  which  pulmonary  stenosis  was  coincident  with  a 
defective  auricular,  but  a  perfect  ventricular,  septum,  the  percentage  was 
almost  the  same  ;  of  those  in  which  there  was  an  associated  defect  of  the 
ventricular  but  none  of  the  auricular  septum,  only  9  survived  the  age  of 
twenty  ;  and  of  those  in  whom  there  were  faults  in  both  septa,  none  passed 
that  age. 

Patency  of  the  foramen  ovale,  without  other  defect,  is  a  common  and  un- 
important fault,  but  it  is  rarely  diagnosed,  so  that  we  are  thus  deprived  of  the 
pleasure  we  might  otherwise  enjoy  of  giving  a  favourable  prognosis  in  the  great 
majority  of  these  cases.  Patients  with  this  fault  have  lived  a  normal  life  without 
knowing  that  there  was  anything  wrong  with  them.  The  same  is  probably  true 
of  limited  defects  of  the  septum  ventriculorum  ;  and  since  this  is  more  readily 
detected  it  offers  some  small  scope  for  the  exercise  of  optimism,  if  one  can  be 
sure  that  no  other  defect  of  a  more  serious  nature  co-exists.  Even  when  the 
septal  faults  are  extreme  and  the  heart  is  three-chambered,  middle  life  may 
be  reached. 

Of  the  other  defects,  congenital  atresia  of  the  tricuspid  valve  is  apparently 
incompatible  with  survival  beyond  the  first  year  of  life.  Only  one-seventh  of 
the  cases  in  which  a  transposition  of  the  great  arterial  trunks  was  found  post 
mortem  had  passed  the  age  of  five.  Patency  of  the  ductus  arteriosus,  if 
uncomplicated  by  other  deformities,  is  compatible  with  the  attainment  of  middle 
life  and  fair  activity. 

Coarctation  of  the  aorta  may  remain  latent  throughout  a  normal  life,  being 
discovered  only  at  the  autopsy.  Of  the  cases  verified  post  mortem,  14  per  cent 
passed  the  age  of  fifty.  The  gross  defects  of  position,  those  in  which  the  heart 
lies  exposed  owing  to  a  thoracic  defect,  are  incompatible  with  more  than  a  ievr 
days  of  extra-uterine  life,  though  one  case  is  described  in  which  life  was  apparently 
maintained  for  a  few  days  by  the  expedient  of  oiling  the  heart  every  three  hours. 


HEART,     WOUNDS     OF  231 

Transposition  of  the  heart,  on  the  other  hand,  makes  no  difference  whatever  to 
the  subject's  expectation  of  Hfe,  and  the  heart  may  even  He  wthin  the  abdomen, 
as  in  Deschamps'  famous  soldier,  without  being  seriously  incommoded. 

Significance  of  Symptoms. — There  are  two  chief  ways  in  which  a  malformation 
of  the  heart  may  be  responsible  for  the  patient's  death  :  cardiac  failure  and 
intercurrent  infections.  The  patient's  liability  to  the  former  is  directly  depen- 
dent on  the  extent  to  which  the  cardiac  defect  embarrasses  his  systohc  efficiency  ; 
and  in  cases  where  the  fault  is  on  the  right  side  of  the  heart,  as  it  is  in  the  great 
majority,  this  may  roughly  be  measured  by  the  degree  of  interference  with  the 
oxygenation  of  the  blood.  Thus,  the  more  cyanosed  the  patient  is,  the  worse 
the  prognosis  ;  and  the  same  generalization  holds  good  for  other  evidences  of 
imperfect  aeration,  such  as  clubbing  of  the  fingers,  dyspnoea,  stunted  growth, 
and  polycythsemia. 

Of  the  intercurrent  infections  to  which  these  unfortunate  persons  are  prone, 
the  most  important  are  malignant  endocarditis  and  certain  pulmonary  infections 
(tuberculosis  and  bronchopneumonia).  The  malformed  heart  seems  to  offer 
a  ready  home  for  streptococci  and  other  organisms  concerned  in  the  production 
of  ulcers  of  the  endocardium  ;  and  though  there  is  some  evidence  that  acute 
inflammatory  lesions  of  the  developmentally  crippled  heart  may  recover,  it  must 
be  acknowledged  that  this  is  a  very  remote  possibility.  Consequently,  anyone 
with  a  congenital  heart  lesion  who  presents  the  symptoms  and  signs  of  an  acute 
blood  infection,  with  or  without  evidences  of  embolism,  is  in  a  bad  way.  The 
vulnerability  to  tuberculosis  is  greater  in  those  patients  who  have  survived  the 
first  decade  ;  when  contracted  it  runs  a  rapid  course.  The  risk  of  this  and  the 
other  pulmonary  infections  is  of  course  increased  if  the  patient's  circumstances 
do  not  admit  of  his  living  a  protected  and  sheltered  life. 

Among  the  causes  of  death  in  cases  of  congenital  heart  disease,  the  possible 
importance  of  associated  malformation  in  other  organs  must  not  be  quite  lost 
sight  of.  One  of  the  writer's  patients  had  pulmonary  stenosis  and  Mongohan 
idiocy,  but  his  death  was  apparently  due  to  the  toxic  effects  of  a  congenital 
dilatation  of  the  colon. 

Sudden  death  is  not  a  very  common  event  in  congenital  heart  disease,  but 
cases  of  all  kinds  may  end  thus.  It  is  impossible  to  lay  down  any  rules  for  the 
foretelhng  of  such  an  event ;  and  with  a  malady  which  is  already  so  crippMng 
to  the  patient's  usefulness,  it  is  probably  better  to  say  nothing  about  it.  In 
patients  with  a  patency  of  the  interventricular  septum  and  drainage  of  both 
ventricles  by  one  arterial  trunk,  sudden  attacks  of  dyspnoea  and  cyanosis  are 
apt  to  cause  great  alarm  ;  here  it  is  possible  to  assure  the  relatives  that  avoidance 
of  the  provocative  factor  (which  is  usually  easy  to  discern)  will  ward  off  further 
attacks. 

To  sum  up,  the  prognosis  in  congenital  cardiac  defect  is  arrived  at  by  making 
a  diagnosis  of  the  actual  condition  present  as  far  as  possible,  and  by  filHng  in 
the  gaps  by  assessment  of  the  degree  of  cardiac  embarrassment  as  revealed  by 
the  symptoms.  Carey  F.  Coombs. 

HEART,  WOUNDS  OF.— Until  Rehn,  of  Frankfurt,  in  1897,  pubhshed  his 
classical  and  successful  case  of  suture  of  a  wound  of  the  heart,  the  injury  was 
regarded  as  mortal,  and  treatment  was  in  the  clouds.  To-day  there  are  scores 
of  recoveries  on  record.  In  England,  where  the  promiscuous  use  of  the  knife  as 
a  means  of  setthng  quarrels  is  not  so  common  as  on  the  Continent,  the  published 
cases  are  very  few,  and  the  writer  is  only  aware  of  one  success  (Somerville). 

No  doubt  the  immense  majority  of  cases  of  wound  of  the  heart  are  fatal  within 
a  few  minutes,  if  not  instantly,  and  this  is  especially  true  of  gunshot  wounds. 


232 


INDEX     OF     PROGNOSIS 


Even  when  thus  produced,  however,  death  may  be  delayed.  In  the  very  desk 
on  which  this  is  being  written  there  reposes  a  pistol  used  by  a  suicide  to  shoot 
himself  through  the  ventricle  (verified  at  autopsy)  ;  as  this  did  not  have  the 
desired  effect,  he  afterwards  turned  the  weapon  upon  his  temple,  and  died  of  a 
pistol-shot  through  the  brain. 

The  cause  of  death  in  stab-wounds  is  not  cardiac  shock.  The  heart  both  of 
animals  and  man  will  withstand  extraordinary  ill-usage.  The  fatality  is  due  to 
the  mechanical  obstruction  of  the  diastole  by  effusion  of  blood  into  the  pericardial 
sac.  A  heart  which  has  almost  or  quite  stopped  beating  has  been  restored  by 
aspiration  of  the  blood  in  the  sac,  and  this  should  be  borne  in  mind  in  deahng 
with  patients  apparently  dead. 

^>^  Turning  to  the  records  of  operation,  there  are  in  the  literature  up  to  igi2  about 
239  cases  treated  by  suture,  whereof  140  died  and  99  recovered,  a  death-rate  of 
58-5'per  cent.  Probably  the  true  death-rate  is  a  little  higher,  some  failures  being 
likely  to  pass  unreported. 

Success  depends  upon  several  factors. 

1.  It  is  essential,  of  course,  that  operation  should  be  very  prompt. 

2.  The  mode  of  obtaining  access  is  important.  A  flap  with  the  hinge  external 
is  less  likely  to  cause  fatal  double  pneumothorax  than  one  with  the  hinge  internal. 
The  stab  wound  has  usually  opened  one  pleura  already. 

3.  Wounds  of  the  auricle  appear  to  be  less  dangerous  than  wounds  of  the 
ventricle.     In  Peck's  series,  the  results  were  as  follows  : — 

Mortality  in  Wounds  of  Heart. 


Region 

Cases 

Died 

Mortality 

Auricles 
Left  Ventricle 
Right  Ventricle 

11 

74 
69 

4 

45 
48 

per  cent 

36 
HI 
70 

Death  usually  occurs  on  the  table,  or  shortly  afterwards  ;  but  some  cases  ha\'e 
developed  aneurysm  (9  on  record)  or  leakage  of  the  suture  line  ;  and  suppuration 
has  been  responsible  for  some  deaths,  especially  if  the  pericardial  sac  was  drained. 

References. — Peck,  Ann.  Surg.  1909,  1,  loi  ;  Pool,  Ibid.  1912,  Iv,  485. 

A.  Rendle  Short. 

HIGH  TENSION,  ARTERIAL.— (See  Arterial  Tension,  High.) 

HIP,    CONGENITAL   DISLOCATION  OF.— {See  Congenital  Dislocation  of 
Hip.) 

HIP,  TUBERCULOUS. — {See  Arthritis,  Tuberculous.) 

HODGKIN'S   DISEASE.— (See  Lymphadenoma.) 

HYDATID  DISEASE. — Hydatid  disease  of  the  liver  and  other  viscera  in  the 
upper  abdomen  will  here  be  considered. 

Prognosis  apart  from  Treatment. — The  condition  may  last  for  many  years 
without  giving  rise  to  trouble  ;  RoUeston  mentions  a  patient  who  had  been 
tapped  for  hydatid  twenty  years  before,  and  in  whom  the  cyst  had  recurred. 
But  a  hydatid  large  enough  to  be  diagnosed  is  always  a  source  of  danger  to  the 
host,  the  principal  risks  being  rupture  and  suppuration. 


HYDRONEPHROSIS  233 

Rupture  may  be  sudden,  or  a  gradual  leakage.  Sudden  rupture  is  often 
fatal.  According  to  Cyr  :  from  rupture  into  the  peritoneal  cavity,  90  per  cent 
die  ;  into  the  pleural  cavity,  80  per  cent  ;  bile-ducts,  70  per  cent  ;  bronchi,  57 
per  cent  ;  stomach,  40  per  cent  ;  intestines,  15  per  cent  ;  on  the  surface,  3  per  cent. 
Occasionally  the  cyst  may  burst  into  the  pericardium  or  inferior  vena  cava  ; 
these  are  usually  fatal  accidents.  If  leakage  takes  place  into  the  peritoneal 
ca\ity,  an  immense  number  of  hydatids  may  keep  on  growing  in  the  abdomen 
and  pelvis.  The  writer  has  seen  a  patient  whose  abdomen  had  to  be  opened 
again  and  again  for  obstruction  and  pelvic  pressure. 

Suppuration  produces  a  large  abscess  of  the  liver  which,  apart  from  treatment, 
is  likely  to  be  fatal. 

Results  of  Treatment. — The  principal  methods  of  treatment  are  by  aspiration 
and  by  enucleation  of  the  cyst. 

Aspiration  has  the  advantage  of  simplicity,  but  not  of  safety.  Leakage  through 
the  puncture  may  follow  and  give  rise  to  peritonitis  or  to  dissemination,  and 
there  are  cases  on  record  where  fatal  haemorrhage  has  resulted.  Although  this 
treatment  is  often  successful,  the  parasite  is  not  always  killed,  and  may  grow  again. 

Enucleation  is  both  more  certain  and  less  risky.  It  is  well  to  inject  the  cavity 
of  the  hydatid  with  a  little  corrosive  subhmate  solution  to  kill  the  scoUces  and 
prevent  dissemination  if  any  fluid  is  spilled. 

Both  after  aspiration  and  after  enucleation,  but  especially  the  former,  curious 
symptoms,  called  by  the  French  '  intoxication  hydatique,'  may  be  met  with 
In  the  milder  cases  there  is  no  m^ore  than  an  attack  of  urticaria.  In  severe  cases, 
which  are  however  very  rare,  there  may  be  collapse,  convulsions,  dyspncea,  and 
death  ^vithin  a  few  hours,  without  urticaria.  Inasmuch  as  this  result  has  been 
met  with  even  when  it  is  certain  that  very  little  of  the  fluid  could  have  been 
spilled,  it  is  probably  a  variety  of  anaphylaxis. 

References. — RoUeston,  Diseases  of  the  Liver,  Gall-bladder,  and  Bile-ducts,  1912, 
410  ;   Deve,  Rev.  de  Chir.  1911,  513.  A.  Rendle  Short. 

HYDRONEPHROSIS. — Prognosis  in  regard  to  Ufa  in  hydronephrosis  depends 
on  the  following  factors  :  (i)  The  nature  of  the  obstruction  ;  (2)  The  condition 
of  the  second  kidney  ;  (3)  The  presence  of  complications  ;  (4)  The  success  of 
operative  measures. 

I.  The  Nature  of  the  Obstruction. — Hydronephrosis  may  be  due  to  malignant 
disease  of  the  bladder  or  other  pelvic  organ.  In  such  cases  the  dilatation  of 
the  kidney  is  moderate  in  degree,  and  there  is  rarely  the  development  of  a 
large  abdominal  swelling.  The  obstruction  is,  however,  bilateral,  and  on  that 
account,  as  wall  be  seen  later,  the  prognosis  is  grave.  The  chief  factor  governing 
the  prognosis  is,  however,  the  malignancy  of  the  growth  causing  the  obstruc- 
tion. The  growth  in  such  cases  is  extensive,  and  from  the  point  of  view  of 
radical  cure  is  inoperable.  The  condition  develops  most  frequently  in  maUgnant 
disease  of  the  bladder,  causing  obstruction  to  the  ureteral  orifices.  It  is  seldom 
that  this  stage  is  reached  without  sepsis  being  superadded,  and  pyonephrosis 
results.  In  malignant  growths  of  the  pelvic  organs  obstruction  of  the  ureters 
takes  place  less  frequently.  It  is  surprising  how  the  ureter  may  be  surrounded 
by  malignant  growth  and  still  remain  pervious. 

Congenital  hydronephrosis  is  usually  due  to  obstruction  in  the  urethra, 
although  occasionally  no  obstruction  can  be  discovered.  The  resulting  dilata- 
tion of  the  kidney  is  bilateral,  and  the  prognosis  is  very  grave,  death  taking 
place  soon  after  Isirth  in  most  cases.  Occasionally  congenital  hydronephrosis 
is  unilateral,  but  in  these  cases  other  congenital  lesions  are  usually  present, 
such  as  cleft  palate,  congenital  atony  of  the  colon,  or  other  conditions,  which 
contribute  to  a  fatal  result  in  early  life. 


234  INDEX     OF     PROGNOSIS 

2.  The  Condition  of  tlie  Second  Kidney. — This  factor,  which  governs  the 
prognosis  in  all  diseases  causing  destruction  of  the  kidney  tissue,  is  especially 
important  in  hydronephrosis. 

a.  Bilateral  Hydronephrosis. — Of  the  various  diseases  which  ma}^  affect  the 
second  kidney  when  one  kidney  is  hydronephrotic,  hydronephrosis  is  the  most 
common.  About  two-thirds  of  cases  of  hydronephrosis  are  bilateral.  In  665 
collected  cases,  Newman  found  217  unilateral  and  448  bilateral. 

Bilateral  hydronephrosis  is  a  progressive  and  fatal  disease.  "When  the 
obstruction  remains  unrelieved,  death  takes  place  after  a  period  which  varies 
greatly,  but  which  always  extends  to  several  years.  The  cause  of  death  is 
destruction  of  kidney  tissue  and  resulting  urjemia.  The  picture  presented 
by  the  patient  is  one  of  gradual  failure  of  the  renal  function.  There  is  progres- 
sive emaciation,  listlessness,  headache,  thirst,  loss  of  appetite,  and,  in  the  later 
stages,  vomiting  v^dth  complete  anorexia,  and  recurring  attacks  of  ureemia. 
The  temperature,  apart  from  intercurrent  infection,  is  subnormal  throughout. 
In  some  cases  of  bilateral  hydronephrosis,  few  symptoms  are  observed  until 
the  very  latest  stages.  A  patient  may  have  two  hydronephrotic  kidneys  which 
form  large  abnormal  tumours  easily  recognized  by  the  eye,  and  appearing  at 
different  times  or  simultaneously,  and  yet  present  no  symptom  of  renal  failure, 
and  enjoy  good,  if  not  robust,  health.  There  is,  however,  the  certainty  that 
the  balance  of  renal  secretion  may  easily  be  upset  by  a  chill  or  other  cause, 
and  death  takes  place  rapidly  from  uraemia  ;  or  that,  if  the  recurring  obstruc- 
tion remains  unreheved,  slow  progressive  renal  failure  will  eventually  supervene. 
The  prognosis  in  bilateral  hydronephrosis  depends  also  upon  the  cause.  Con- 
genital hj'dronephrosis,  and  hydronephrosis  due  to  malignant  growths  in  the 
pelvic  organs,  are,  as  already  stated,  beyond  surgical  aid,  and  are  invariably 
fatal.  Where  the  obstruction  is  remediable,  as  in  urethral  obstruction,  stone, 
obstructing  bands,  vessels,  valves,  kinks,  etc.,  the  prognosis  depends  upon  how 
far  the  destruction  of  renal  tissues  has  been  allowed  to  progress  before 
operation  ;  in  other  words,  upon  the  ability  of  the  medical  attendant  to  make 
an  early  diagnosis.     The  results  of  operation  will  be  referred  to  later. 

b.  Other  Diseases  of  the  Second  Kidney. — In  8  collected  cases  of  anuria 
following  operation  upon  a  hydronephrotic  kidney,  the  second  kidney  was 
hydronephrotic  in  2,  atrophic  in  2,  the  seat  of  nephritis  in  2,  and  there  was  no 
second  kidney  in  2  cases.  The  prognosis  in  all  these  cases,  apart  from  any 
operation,  is  very  grave,  and  the  fatal  issue  cannot  be  long  delayed. 

3.  The  Occurrence  of  Complications. 

a.  Infection. — The  most  common  complication  is  infection  of  the  hydro- 
nephrosis, and  this  has  an  important  bearing  on  the  form  of  operation,  and  on 
the  ultimate  result  of  the  disease.  A  hydronephrosis  is  dangerous  to  life  merely 
from  the  destruction  of  kidney  tissue.  If  infection  is  added,  this  destruction 
takes  place  more  rapidly  and  completely,  and  further,  the  danger  of  absorption 
from  a  large  pus-containing  cavity  is  superadded. 

A  very  considerable  proportion  of  cases  of  hj'dronephrosis  eventually  become 
infected.  The  entrance  of  bacteria  may  take  place  by  way  of  the  urethra  and 
bladder  after  catheterization,  but  much  more  frequently  the  infection  is 
haematogenous  in  origin.  Whether  infection  takes  place  directly  through  the 
wall  of  the  hydronephrosis  from  the  overhang  and  occasionally  densely  adherent 
bowel,  is  not  certainly  known.  It  appears  likely  that  infection  may  take  this 
route.  It  may  be  of  a  mild  character,  so  that  the  contents  of  the  dilated  kidney 
are  cloudy,  and  the  deposit  small  in  amount  ;  such  an  infection  does  not 
endanger  life  from  absorption,  or  militate  against  the  success  of  plastic  opera- 
tions on  the  kidney.     On  the  other  hand,  the  infection  may  take  a  more  active 


HYDRONEPHROSIS 


235 


form,  and  the  dilated  kidney  contain  a  large  quantity  of  pus,  while  there  are 
a  high  swinging  temperature  and  other  signs  of  toxaemia.  The  prognosis  in 
such  a  case  is  much  more  grave,  death  taking  place  in  unrelieved  cases  from 
toxic  absorption,  or  from  this  combined  with  uraemia.  It  is  rarely  possible  to 
operate  in  such  cases  with  the  object  of  preserving  the  remaining  kidney  sub- 
stance, and  the  choice  lies  between  a  palliative  nephrotomy  and  nephrectomy. 

b.  Rupture  of  Hydronephrosis.— This  is  by  no  means  common,  and  is  almost 
invariably  the  result  of  injury,  although  this  may  occasionally  be  of  a  trifling 
character.  In  children,  rupture  into  the  peritoneal  cavity  may  take  place,  causing 
fatal  peritonitis  ;  in  the  adult  the  rupture  is  extraperitoneal,  and  may  cause  death 
from  suppression  of  urine.     Recovery  may,  however,  follow  prompt  operation. 

c.  TJrcemia. — This  is  the  last  stage  of  hydronephrosis  when  the  second  kidney 
is  absent,  or  so  far  diseased  as  to  be  incapable  of  performing  the  renal  function. 

4.  The  Success  of  Operative  Measures. — The  success*,  or  failure  of  operation 
for  the  removal  of  obstruction  in  the  urethra,  bladder,  or  renal  pelvis  depends 
upon  the  nature  of  the  obstruction. 

Nephrotomy  has  been  performed  in  congenital  bilateral  hydronephrosis, 
without  averting  a  fatal  result.  It  may  be  used  as  a  preliminary  to  plastic 
operation  on  the  kidney. 

Nephropexy,  nephrolithotomy,  the  removal  of  bands  and  of  aberrant  renal 
vessels,  and  plastic  operations  on  the  renal  pelvis,  its  outlet,  and  the  ureter, 
may  be  required. 

The  degree  of  success  attending  any  of  these  operations  depends  upon  the 
early  diagnosis  of  hydronephrosis.  It  is  now  possible  by  means  of  p5'-elography 
to  make  a  diagnosis  before  the  kidney  has  reached  such  a  size  that  enlargement 
can  be  detected  on  palpation  of  the  abdomen.  If  this  is  done  and  the  obstruc- 
tion remedied,  the  kidney  can  be  saved  with  little  damage  to  its  secreting 
substance. 

In  the  later  stage  of  hydronephrosis,  when  a  palpable  tumour  can  be  detected 
in  the  abdomen,  the  kidney  tissue  is  expanded  and  much  destroyed.  The 
removal  of  the  obstruction  does  not  restore  the  kidney  to  its  normal  state, 
and  only  saves  what  remains  of  the  secreting  substance.  In  the  fully  developed 
hydronephrosis,  when  the  layer  of  kidney  tissue  is  reduced  to  half  an  inch  or 
less  in  thickness,  the  organ  still  retains  a  considerable  degree  of  functional  power. 
I  have  operated  on  both  kidneys  in  a  case  of  bilateral  hydronephrosis,  when 
each  organ  was  reduced  to  a  thin  shell,  and  the  patient  is  well  and  without 
renal  symptoms  four  and  a  half  years  after  the  operation.  There  are  cases  of 
bilateral  advanced  hydronephrosis  in  which  the  patient  has  lived  for  many  years, 
and  there  are  other  cases  where  a  solitary  kidney  has  been  converted  into  a 
hydronephrotic  sac,  and  yet  carried  on  a  renal  function  sufficient  to  maintain  life. 

Schloffer  collected  86  plastic  operations  with  the  following  results  : — 


Operation 

Cases 

Deaths 

Failures 

Section    of    valves 
Uretero-pyeloplasty 
Uretero-pyeloneostomy 
Lateral  anastomosis  (ureter) 
Plastic    operation    in    renal 
pelvis      .... 
Pyeloplication 
Orthopajdic  resection    - 
Combined  operations    - 

12 
18 
19 
13 

1 

4 

8 

11 

1 
1 
2 

2 
1 

3 
4 
fi 
3 

1 

86 

7 

17 

235  INDEX     OF     PROGNOSIS 

Nephrostomy,  or  incision  and  drainage  of  the  sac,  without  any  attempt  to 
overcome  the  cause  of  the  obstruction,  is  sometimes  performed.  It  is  said  to 
have  resulted,  in  from  30  to  45  per  cent  of  cases,  in  re-estabhshment  of  the 
flow  of  urine  through  the  ureter  and  heahng  of  the  nephrostomy  wound  ;  in 
the  remaining  cases  a  fistula  persisted. 

Primary''  nephrectomy  is  only  indicated  when  the  sac  is  very  large  and  its 
wall  so  thin  and  fibrous  that  no  renal  tissue  is  present,  and  should  only  be 
undertaken  when  it  can  be  proved  that  a  second  kidney  is  present  and  efficient. 
Kiimmel  performed  nephrectomy  on  35  cases  of  unilateral  hydronephrosis,  with. 
I  death,  and  the  late  results  of  the  operation  were  uniformly  good. 

/.  W.  Thomson  Walker. 

IDIOCY. — {See  Mental  Diseases.) 

IMPERFORATE   ANUS. — [See  Anus,  Imperforate.) 

INFANTILE  CONVULSIONS. — Convulsive  attacks,  with  symptoms  more 
or  less  resembling  those  of  epilepsy,  may  occur  in  infants  of  various  ages.  Here, 
as  in  aU  other  diseases,  the  prognosis  depends  upon  the  accuracy  of  diagnosis  of 
the  underlying  cause. 

In  newly-born  children,  con\ailsions  may  occur  immediately  after  birth,  or 
within  a  few  days.  They  are  specially  common  after  a  prolonged  and  difficult 
labour,  and  first-bom  children  are,  therefore,  more  hable  to  such  convulsions  than 
later-born  children.  In  these  birth -convulsions,  the  convulsive  movements, 
if  hmited  to  one  side,  are  strongly  suggestive  of  a  cortical  haemorrhage, 
generally  from  rupture  of  meningeal  veins.  If  such  hemorrhage  be  so  severe 
as  to  produce  structural  changes  in  the  cerebral  cortex,  the  unilateral  convulsions 
are  likely  to  be  followed  by  permanent  hemiplegia,  more  or  less  profound. 
Bilateral  cortical  hsemorrhages,  from  the  same  causation,  produce  bilateral 
symptoms  of  the  same  kind,  and  are  amongst  the  commonest  causes  of  bilateral 
hemiplegia  (diplegia).  As  birth-haemorrhages  are  generally  situated  on  the 
vertex,  the  cortical  centres  which  are  situated  nearest  to  the  middle  hne — ^i.e., 
the  centres  for  the  lower  hmbs — are  most  severely  affected  ;  hence  the  resulting 
hemiplegia  or  diplegia  is  usually  most  intense  in  the  legs. 

Other  newly-born  children  suffer  from  convulsions  which  are  apparently  the 
result  of  excessive  venosit}^,  or  other  morbid  condition,  of  the  blood,  without 
actual  cortical  haemorrhage.  Such  children  are  cyanosed,  and  may  be  severely 
convulsed,  but  the  convulsions  do  not  show  the  same  constant  commencement 
on  the  same  side  ;  they  vary  in  their  mode  of  onset,  starting  sometimes  on  one 
side,  sometimes  on  another.  In  such  cases,  the  prognosis  as  to  the  absence  of 
subsequent  paralysis  is  better  than  in  persistently  unilateral  convulsions. 

Many  cases  of  generahzed  con\Tilsions  occur  later  in  infancy,  independent  of 
any  evidence  of  difficult  labour.  Such  cases  are  most  commonly  toxic  in  origin, 
e.g.,  during  attacks  of  diarrhoea  from  dietetic  faults.  In  these  cases,  if  the  gastro- 
intestinal irritation  be  treated  by  suitable  food  and  intestinal  antiseptics,  the 
convulsions  rapidly  subside ;  nor  do  they  tend  to  recur  or  to  have  any  paralytic 
sequelae. 

Still  later  in  infancy,  at  the  age  of  eight  or  nine  months,  we  meet  with  so-called 
'  teething  convulsions.'  Doubtless  the  irritation  of  the  first  dentition  is  an 
exciting  factor,  but  the  predisposing  and  underlying  cause  is  usually  rickets. 
Convulsions  in  rickety  children  are  generally  bilateral.  In  severe  cases,  they  may 
resemble  an  epileptic  fit ;  in  other  cases,  the  symptoms  are  much  less  severe, 
consisting  in  sudden  pallor  of  the  face  and  lips,  with  fixation  of  the  ej^es,  and  some- 
times transitory  squint,  the  limbs  and  trunk  meanwhile  becoming  rigid ;   in  other 


INFANTILE    PARALYSIS 


237 


cases  again,  clonic  movements  appear,  especially  in  the  face,  hands  and  feet. 
Whatever  be  the  particular  variety  of  symptoms  present,  they  are  always  bila- 
teral. Unilateral  spasms  generally  indicate  focal  disease,  and  have  an  entirely 
different  prognosis. 

The  onset  of  any  acute  fever  in  an  infant  may  be  accompanied  by  convulsions  ; 
these  are  generalized  and  bilateral,  and  do  not  tend  to  recur  after  the  temperature 
has  become  normal.  Even  in  the  absence  of  fever,  conditions  of  temporary 
cyanosis — e.g.,  during  a  paroxysm  of  whooping-cough — may  cause  a  generalized 
convulsive  attack. 

Convulsions  of  unilateral  distribution,  often  associated  with  high  temperature 
and  delirium,  indicate  a  localized  cortical  lesion  of  some  sort,  most  commonly  due 
to  the  virus  of  acute  polio-encephalitis.  If  the  morbid  process  destroys  a  portion 
of  the  motor  cortex,  it  is  followed  by  a  corresponding  permanent  hemiplegia  or 
monoplegia  of  the  face,  arm,  or  leg,  as  the  case  may  be,  such  weakness  varying  in 
intensity  from  a  sUght  paresis  to  a  profound  hemiplegia.  Moreover,  in  this 
variety  of  infantile  hemiplegia,  there  is  a  subsequent  tendency  to  recurrent- 
convulsions  on  the  hemiplegic  side  of  the  body. 

In  the  convulsions  of  meningitis — tuberculous,  meningococcal,  etc. — the 
prognosis  is  that  of  the  underlying  disease.  In  cases  of  this  sort,  examin?tion 
of  the  cerebrospinal  fluid  gives  us  valuable  diagnostic  and  prognostic  indications. 
{See  Meningitis.)  Purves  Stewart. 

INFANTILE  DIARRHCEA.— (See  Diarrhoea,  Infantile.) 

INFANTILE  PARALYSIS. — Pohomyehtis  anterior  used  to  be  regarded  as  a 
disease  per  se,  but  recent  observations  have  now  established  the  fact  that  it  is  but 
one  variety  of  a  wider-spread  malady  of  infective  origin,  which  attacks  the  central 
nervous  system  and  its  meninges,  having  a  selective  action  upon  the  motor  nerve- 
cells.  When  the  brain  cortex  is  affected,  we  call  the  disease  polio-encephahtis 
superior  ;  when  the  motor  nuclei  in  the  bulb  are  attacked,  we  call  it  poho- 
encephalitis  inferior ;  and  when  the  anterior  cornua  of  the  spinal  cord  are  affected, 
we  term  it  pohomyehtis  anterior. 

Polio-encephalo-myelitis,  then,  is  a  febrile  disease.  It  has  an  incubation 
period  of  six  to  eight  days,  and  a  febrile  phase  lasting  about  three  or  four  days. 
The  muscular  paralysis  appears  during  the  stage  of  pyrexia.  If  the  cortical 
motor  cells  are  affected  (polio-encephalitis  superior),  there  are  usually  convulsions 
at  the  start ;  these  subside,  and  may  leave  the  child  monoplegic,  hemiplegic,  or 
diplegic,  according  to  the  extent  of  permanent  cortical  destruction.  If  the 
cells  of  the  spinal  cord  are  mainly  attacked  (poliomyelitis  anterior),  there  is  a 
widespread  flaccid  paralysis  of  the  trunk  and  limbs,  varying  in  distribution  in 
different  cases,  and  corresponding  to  the  extent  of  grey  matter  that  is  affected. 
The  initial  paralysis  reaches  its  maximum  in  a  few  hours,  and  is  always  more 
widespread  than  the  permanent  residuum  of  muscular  atrophy ;  for  many  of  the 
nerve-cells  during  the  acute  stage  of  the  disease  are  merely  affected  by  inflam- 
matory and  cedematous  changes,  and  if  there  is  nothing  beyond  an  inflammatory 
oedema,  there  is  a  possibihty  that  the  cells  may  still  recover.  If,  however,  some 
of  the  nerve-cells  are  actually  destroyed  by  the  inflammatory  process,  as  is 
generally  the  case,  the  corresponding  muscle-fibres  undergo  permanent  atrophy 
and  paralysis. 

It  v.dll  be  seen,  from  what  we  have  said,  that  the  prognosis  of  this  disease  differs 
according  to  the  stage  at  which  it  comes  under  observation. 

During  the  acute  febrile  stage,  if  there  is  no  implication  of  the  vital  medullary 
centres,  and  the  patient  survives,  the  probabilities  are  that  the  paralysis  will,  in 


238  INDEX     OF     PROGNOSIS 

time,  clear  up  to  a  certain  extent.  It  is  even  possible  that  if  the  cells  have  been 
merely  oedematous,  and  not  actually  destroyed,  they  may  all  recover,  and  the 
initial  flaccid  paralysis  or  paresis  of  the  limbs  or  trunk  clear  up  completely.  This, 
however,  is  uncommon,  and  it  is  more  usual  to  find  that,  whilst  some  muscles  re- 
cover, other  muscle-groups  remain  feeble  and  undergo  wasting,  indicating  that 
destructive  changes  have  occurred  in  the  anterior  cornual  cells. 

When  the  acute  febrile  stage  has  passed  off,  the  question  of  the  amount  of 
permanent  recovery  arises.  This  question  is  best  answered  by  a  consideration 
of  the  electrical  reactions  of  the  affected  muscles,  especially  the  faradic  reactions. 
We  wait  until  ten  days,  at  least,  have  elapsed  from  the  time  of  onset  of  the 
paralysis,  in  order  to  allow  time  for  degenerative  changes  in  the  nerve-cells  and 
muscle-fibres  to  be  recognizable.  After  ten  days  or  a  fortnight,  when  some  of 
the  muscles  have  recovered  voluntary  power,  whilst  others  are  still  flaccid  and 
paralyzed,  we  proceed  to  examine  these  paralyzed  muscles  electrically.  Those 
which  still  react  to  faradism  will  ultimately  recover,  those  in  which  faradic 
excitability  is  lost  will  probably  remain  permanently  paralyzed.  Other  muscles, 
again,  show  mere  diminution  in  faradic  response  ;  these  will  recover  to  some 
extent.  The  recovery  of  those  muscles  which  are  recoverable  will  be  hastened 
by  assiduous  skilled  massage  and  passive  movements. 

If  the  patient  is  already  in  the  chronic  stage  by  the  time  he  comes  under 
observation,  we  have  now  to  deal  with  the  relics  of  an  antecedent  disease. 
Presuming  that  all  the  surviving  muscles  have  been  brought  to  their  maximum 
development  by  a  preliminary  course  of  suitable  massage  and  electrical  treat- 
ment, lasting  six  months  or  longer,  we  have  now  to  consider  the  prospects  of 
preventing  or  diminishing  deformities,  and  of  enabling  the  patient  to  make  some 
use  of  his  paralyzed  limb.  This  is  largely  a  matter  for  the  ingenuity  of  the 
orthopaedic  expert.  When  the  limb  is  flaccid  and  flail-like,  the  question  of  fixation 
of  certain  joints  arises.  This  can  sometimes  be  accomplished  by  arthrodesis;  at 
other  times  by  the  application  of  a  light  splint,  preferably  made  of  celluloid.  In 
other  cases  again,  where  the  muscles  on  one  aspect  of  a  joint  are  paralyzed,  whilst 
their  antagonists  are  still  active,  transplantation  of  the  insertions  of  muscles  or 
tendons  from  the  healthy  to  the  paralyzed  aspect  of  the  joint,  together  with 
division  or  lengthening  of  shortened  tendons,  may  serve  to  restore  a  certain 
measure  of  useful  mobility  to  a  joint,  and  to  correct  deformities.  Surgical 
measures,  however,  should  not  be  thought  of  until  the  limb  has  had  a  previous 
thorough  course  of  massage  and  passive  movements  for  several  months  at  least. 
It  is  astonishing  how  often  a  limb,  which  at  first  seemed  hopelessly  paralyzed, 
recovers  part  of  its  motor  power,  without  the  necessity  for  surgical  interference. 
{See  also  Talipes.)  Purves  Stewart. 

INFERIOR  VENA  CAVA,  WOUNDS  OF. — The  inferior  vena  cava  is  occasion- 
ally ruptured  by  contusion  of  the  abdomen,  and  this  is  a  cause  of  very  rapid 
death.  The  writer  has  seen  one  such  case.  The  effusion  of  blood  was  very 
small,  but  apparently  the  heart  failed  because  it  received  an  inadequate  quantity. 

The  inferior  vena  cava  has  several  times  been  torn  in  removing  a  right  kidney. 
Albarran  considers  that  the  best  treatment  is  to  ligature  it ;  he  collects  from  the 
hterature  records  of  5  cures  and  2  deaths  following  this  procedure. 

A.  Rendle  Short. 

INFLUENZA. — The  prognosis  in  influenza  depends  primarily  on  the  virulence 
of  the  organism,  which  varies  greatly  in  different  epidemics.  Uncomplicated 
influenza  is  rarely  dangerous  to  life.  The  mortality  in  the  epidemic  of  1889- 
1890  was  in  Munich  o-6  per  cent,  in  Mecklenburg-Schwerin  1-2  per  cent,  in 
Leipzig  0-5  per  cent,  in  the  German  army  01  per  cent,  in  fifteen  Swiss  towns 


INFLUENZA  239 


o-i  per  cent.     These  figures  do  not  include  cases  of  death  from  influenzal  pneu- 
monia.    The  mortality  from  this  varies  from  15  to  26  per  cent. 

The  increase  in  the  general  mortality-rate  during  an  epidemic  of  influenza 
is  chiefly  due  to  increased  mortality  from  acute  diseases  of  the  respiratory 
organs,  and  to  a  rise  in  the  death-rate  of  pulmonary  tuberculosis.  In  the  whole 
of  Germany  during  the  epidemic  of  1 889-1 890,  about  66,000  succumbed. 
Owing  to  the  more  malignant  character  of  subsequent  epidemics  both  in  England 
and  Germany,  the  death-rates  were  higher.  Thus,  deaths  from  influenza  in 
London  from  January  to  March,  1890,  were  558  ;  from  May  to  July,  1891, 
2104  ;    from  January  to  March,  1892,  2078. 

The  influenzal  bacilli  may  remain  for  a  long  time  in  the  sputum  in  phthisical 
cases,  especially  in  patients  with  pulmonary  cavitation,  whereas  they  generally 
disappear  after  a  few  days  in  a  typical  acute  case  arising  in  a  previously  healthy 
person. 

In  some  cases  the  initial  symptoms  are  extremely  severe  and  sudden  in  onset. 
For  example,  the  disease  may  be  ushered  in  with  convulsions,  coma,  severe 
vertigo,  or  even  acute  mental  symptoms,  and  yet  the  patient  may  be  well  in  a 
few  days.  As  a  rule,  after  an  uncomplicated  attack,  the  patient  passes  through 
a  rapid  convalescence  ;  but  in  other  cases,  when  the  course  of  the  illness  has 
been  apparently  in  all  respects  identical,  convalescence  is  extremely  long  and 
tedious,  owing  to  great  debility,  loss  of  energy  both  bodily  and  mental, 
insomnia,  anorexia,  and  gastric  disturbance. 

Influenza  is  prone  to  relapse  after  a  few  days'  interval,  and  not  very  infrequently 
the  relapse  is  much  more  serious  than  the  original  attack.  Moreover,  pulmonary 
trouble,  which  was  at  first  absent,  may  now  supervene. 

With  reference  to  the  pulmonary  form,  in  addition  to  the  prognostic  points 
common  to  any  form  of  pneumonia,  a  guarded  prognosis  should  be  given  even 
when  the  temperature  has  fallen  to  normal,  as  it  is  not  very  unusual  to  have  a 
second  or  even  a  third  pneumonic  attack  following  closely  one  on  the  other. 
A  particularly  fatal  form  is  that  of  acute  hypersemia  of  the  lungs,  associated 
with  dyspnoea  and  cyanosis,  sometimes  with  sanguineous  sputum,  but  without 
pneumonic  change.  Such  patients  very  often  die  after  a  few  days  with  cardiac 
asthenia  and  tachycardia. 

In  some  cases,  resolution  of  the  pneumonic  lung  may  be  delayed  for  weeks, 
sometimes  even  for  months,  after  which  the  lung  may  become  completely 
clear.  It  is  well,  therefore,  not  to  be  too  premature  in  asserting  that  the  patient 
is  suffering  from  an  indurative  pneumonia,  or,  if  the  lesion  happens  to  be  at 
the  apex,  that  the  patient  is  becoming  tuberculous.  On  the  other  hand,  an 
influenzal  infection  certainly  does  not  infrequently  pave  the  way  for  a  tuberculous 
lesion.  Further,  latent  phthisis  may  become  active,  and  healing  foci  break  out 
afresh.  Phthisical  patients  show  a  special  predisposition  to  influenza,  and 
influenzal  patients  to  an  increase  of  any  tuberculous  lesion  present. 

With  reference  to  the  prognosis  of  influenzal  encephalitis,  it  is  usual  for  the 
resulting  paralysis  to  clear  up  entirely  if  the  patient  does  not  succumb  to  the 
severity  of  the  attack.  The  prognosis  is  grave  in  cases,  which  generally  occur 
in  children,  which  assume  all  the  characters  of  meningitis,  including  con- 
vulsions, headache,  vomiting,  coma,  cervical  rigidity,  strabismus,  mydriasis, 
inequality  of  pupils,  grinding  of  teeth,  bradycardia,  and  irregular  respiration. 
According  to  some  authors,  the  prognosis  of  influenzal  epilepsy  is  decidedly 
better  than  in  many  other  forms.  The  prognosis  of  uncomplicated  influenzal 
psychosis  is  as  a  rule  favourable,  but  it  may  last  for  weeks,  or  even  months. 

Influenza  occasionally  exerts  its  influence  almost  entirely  on  the  heart,  and 
when  this  occurs  the  outlook  is  very  grave.     There  is  a  great  tendency  to  syncope. 


240  INDEX     OF     PROGNOSIS 


the  pulse  is  rapid,  irregular,  and  feeble,  with  pallor,  precordial  distress,  and 
sometimes  sweating.  When  recovery  takes  place,  convalescence  is  extremely 
tedious  as  a  rule,  and  is  associated  with  prolonged  disturbance  of  the  heart's 
action:  this  is  generally  rapid  and  irregular,  though  sometimes  bradycardia 
with  intermittent  action  persists. 

An  attack  of  influenza  influences  patients  suffering  from  diabetes  very 
unfavourably,  and  they  not  infrequently  die  in  coma.  It  may  also  lead 
to  abortion  in  a  pregnant  woman,  and  in  this  way  render  the  prognosis 
exceedingly  grave  if  pneumonia  is  also  present.  In  some  rare  cases,  repeated 
rigors  occur  throughout  the  course  of  the  illness.  These  may  arise  without 
the  formation  of  pus,  pneumonia,  or  obvious  visceral  changes,  and  although 
the  prognosis  must  be  guarded,  owing  to  the  severity  of  the  cases,  too  gloomy 
an  outlook  should  not  be  given.  j.  7j.  Charles. 

INSANITY.— (See  Mental  Diseases.) 

INTESTINAL  OBSTRUCTION.— Under  this  heading  we  shall  include  cases 
of  acute  intestinal  obstruction  due  to  cancer,  faecal  impaction,  bands,  apertures, 
Meckel's  diverticulum,  and  volvulus.  Intussusception,  strangulated  hernia, 
and  chronic  obstruction  due  to  cancer  of  the  colon  or  rectum,  are  dealt  with  in 
other  articles. 

The  most  essential  element  in  the  prognosis  is  to  make  a  careful  distinction 
between  faecal  impaction  and  organic  obstruction.  Many  cases  of  simple  impac- 
tion recover  with  ordinary  treatment  such  as  purgatives  and  enemata  ;  when 
organic  obstruction  is  present,  recovery  apart  from  operation  is  next  to  impossible. 
In  practice,  however,  the  distinction  between  the  two  may  be  extremely  difficult, 
and  most  surgeons  have  seen  a  patient  refuse  a  laparotomy,  and  recover  never- 
theless. Of  course,  if  a  mass  of  hard  faeces  can  be  felt  in  the  rectum  or  colon, 
or  if  copious  enemata  immediately  bring  away  a  large  evacuation,  the  diagnosis 
is  clear.  The  difficult  cases  are  constipated  elderly  people  with  a  swollen  or  fat 
abdomen  in  which  nothing  can  be  felt,  who  have  vomited  once  or  twice,  and  are 
not  relieved  by  enemata.  It  is  much  safer  to  explore  the  abdomen,  if  enemata 
fail  and  nothing  can  be  felt  in  the  rectum,  without  waiting  to  see  if  spontaneous 
recovery  will  take  place. 

It  is  probable  that  in  a  few  rare  instances  the  bowel  has  escaped,  by  some 
lucky  accident,  from  an  organic  strangulation  ;  but  almost  invariably  it  is 
paralyzed  soon  after  it  becomes  ensnared.  Still,  these  occurrences  will  lead  a 
practitioner  who  values  his  reputation  not  to  be  too  '  cock-sure  '  in  threatening 
death  to  a  patient  who  refuses  operation.  The  practical  rule,  however,  is  that 
if  repeated  enemata  fail,  and  vomiting,  abdominal  pain  and  distention,  and 
constipation  are  present,  death  within  a  few  days  is  all  but  certain,  apart  from 
operation.  One  ought  not  to  wait  for  faecal  vomiting  ;  that  is  a  death-door 
phenomenon.  Patients  with  foul  vomit  may  recover  after  operation  ;  those 
with  vomit  smelling  of  faeces,  very,  very  seldom.  The  most  common  cause  of 
death  is  toxaemia,  then  peritonitis,  and  occasionally  lung  complications.  Death 
on  the  table  from  inhaling  foul  vomit  is  by  no  means  a  negligible  cause  of  fatality. 

Results  of  Operation. — It  is  not  easy  to  gauge  accurately  the  present-day 
mortality  of  intestinal  obstruction  treated  by  surgical  means  ;  cases  are  operated 
on  at  all  stages,  for  so  many  types  of  obstruction,  and  in  so  many  different  ways. 
Some  statistics,  such  as  McClannan's,  are  complicated  by  the  inclusion  of  an 
unspecified  number  of  strangulated  hernia  cases.  The  most  reUable  figures 
available  are  the  records  for  the  years  1887  to  1907  from  St.  Thomas's  Hospital, 
and  those  published  by  Gibson,  though  they  are  by  no  means  recent.     By  a 


INTESTINAL     OBSTRUCTION  241 

combined  study  of  the  literature  and  hospital  reports,  Gibson  published  in  1910 
the  results  of  646  cases,  whereof  312  died,  that  is,  47  per  cent.  This  includes 
patients  with  intussusception,  but  does  not  include  cancer.  Treves  (1899)  and 
Moynihan  (1906)  both  agree  that  the  actual  mortality  is  probably  50  per  cent, 
but  Moynihan  declares  that  this  is  a  reproach,  and  that  "  anything  over  10  per 
cent  is  the  mortality  of  delay."  In  the  St.  Thomas's  figures  the  death-rate  in 
simple  cases  was  56-7  per  cent,  and  in  inahgnant  cases  65  per  cent. 

How  much  the  time  of  operation  influences  the  death-rate  is  shown  by  Gibson's 
figures,  as  given  in  the  following  table  (the  figures  do  not  include  intussusception, 
hernia,  or  cancer). 

Mortality  according  to  Day  of  Operation. 


Day  of  Operation 

Cases 

Died 

Percentage 

First   -        -        -        - 

16 

6 

.    37 

Second 

44 

17 

38-5 

Third - 

61 

25 

41 

Fourth        -        -        . 

70 

27 

38-5 

Fifth  -        -        -        - 

62 

30 

48 

Sixth  -        .        -        - 

44 

29 

66 

Seventh 

28 

15 

53-5 

Later  -        -        -        - 

107 

59 

55 

The  Varieties  of  Obstruction. — We  must  now  take  up  each  form  of  obstruc- 
tion separately. 

Fcecal  impaction  and  foreign  bodies  produce  a  form  of  obstruction  which  is 
relatively  favourable,  and  which  will  usually  yield  to  simple  measures  such  as 
enemata.  Death  from  faecal  impaction  is  very  unusual,  unless  the  patient  is 
utterly  neglected.  It  is  astonishing  how  long  they  may  survive  without  an 
action  of  the  bowels  ;  one  patient,  reported  by  Harris,  was  seen  fifty-three  days 
after  the  last  evacuation  ! 

Obstruction  by  bands  or  kinks  is  not  favourable,  because  the  small  intestine  is 
involved.  The  higher  the  block,  the  worse  the  outlook.  According  to  Treves, 
the  average  length  of  life  is  about  five  days,  the  extremes  being  eight  hours  and 
twenty  days.  In  Gibson's  186  cases,  41  per  cent  died.  The  treatment  was 
usually  division  of  the  band  ;  on  17  occasions  resection  was  necessary  ;  and  an 
artificial  anus  was  made  in  22.  Practically  all  these  last  died.  Of  102  cases  at 
St.  Thomas's,  35  recovered  and  67  died. 

Volvulus,  when  not  treated  by  operation,  has  an  average  duration  of  six  days, 
the  extremes  being  sixty-four  hours  and  twenty  days  (Treves).  Corner  and 
Sargent,  reporting  on  57  cases  from  St.  Thomas's  Hospital  over  many  years, 
found  19  recoveries  and  21  deaths.  Gibson  gives  the  death-rate  as  54  per  cent  : 
when  the  loop  was  untwisted,  31  out  of  79  died  ;  when  resected,  13  out  of  16  ; 
when  an  artificial  anus  was  made,  the  fatahties  amounted  to  16  out  of  20. 

Finsterer,  using  the  published  records  of  various  German  and  Austrian 
surgeons,  believes  that  resection  gives  better  results  than  detorsion.  In  his 
whole  series  (up  to  1912)  of  no  cases,  37  per  cent  died;  resection  and  imme- 
diate end-to-end  anastomosis  had  a  mortality,  if  the  gut  was  not  gangrenous,  of 
only  7  per  cent  in  29  cases.  It  is  difficult  to  accept  tliis  as  a  fair  representation, 
however.  Most  surgeons  consider  end-to-end  anastomosis  in  the  presence  of 
acute  obstruction  very  dangerous.  Finsterer's  cases  probably  include  a  dispro- 
portionate number  of  pubhshed  successes. 

16 


242 


INDEX     OF     PROGNOSIS 


Jankowski  has  reported  5  cases  of  volvulus  of  the  caecum,  of  which  2  were 
cured  and  3  died  ;  he  also  reported  48  cases  of  volvulus  of  the  pelvic  colon 
operated  on  in  Riga  during  ten  years  (1903-1913).  The  results  are  shown  in  the 
following  table : — 

Results  of  Operation  for  Volvulus  of  the  Pelvic  Colon  (Jankowski). 


Operation 

Cases 

Cured 

Died 

Detorsion  and  fixation  of  mesocolon     - 
Enterotomy  and  fixation 
Short-circuiting  (caecum  to  rectum) 
Resection  of  loop     ----- 
Gangrene  already  present 

11 

4 

6 

3 

24 

11 
3 
1 

2 
2 

0 

1 

5 
1 

22 

Gall-stone  impaction,  for  some  reason  or  other,  is  not  as  favourable  as  one 
would  have  thought.  In  Gibson's  series  of  40  cases,  57  per  cent  died  ;  and  in 
two  long  lists  of  280  and  105  respectively,  quoted  by  Treves  in  1899,  the 
mortality  was  about  the  same  [see  Gall-stones).  These  statistics  are  all 
somewhat  ancient. 

Meckel's  diverticulum  caused  obstruction  in  42  of  Gibson's  cases,  and  62  per 
cent  died.  Division  or  excision  was  practised  30  times,  with  17  deaths  ;  resection 
of  bowel  5  times,  with  4  deaths  ;  and  an  artificial  anus  was  made  in  4  cases, 
with  3  deaths.     At  St.  Thomas's  Hospital,  14  out  of  22  died. 

Mortality  according  to  Form  of  Obstruction  (Gibson.). 


Cause  of  obstruction 


Foreign  bodies 

Bands 

Volvulus    -        - 

Gall-stone  impaction 

Meckel's  diverticulum 

Bowel  snared  in  openings  or  fossae 


per  cent 

16 

25 

186 

41 

121 

54 

40 

57 

■   42 

62 

34 

62 

Results  of  Operation  for  Intestinal  Obstruction  at  St.  Thomas's 
Hospital,  1887-1907. 


Nature 

Total 

Recovered                Died 

Mortality 
per  cent 

Intussusception        .         .         .         . 
Volvulus          -         -      _  - 
Broad  peritoneal  adhesions 
Cicatricial  bands      .         .         -         - 
Mesenteric  holes      .         .         -         - 
Meckel's  diverticulum 
Cicatricial  stricture 
Gall-stone  impaction 
Various  -         -         -         - 

202 
29 
60 

42 

9 

5 
26 

109 

10 

24 

11 

0 

8 

1 

1 

9 

93 
19 

3() 

31 
5 

14 
8 
4 

17 

46 
65-5 
60 
74 
100 
64 
89 
80 
65 

Malignant  disease  of  bowel     - 

400 
137 

173 

48 

227 
89 

56-7 
65 

INTRACRANIAL    COMPLICATIONS    OF    EAR   DISEASE         243 


Incarceration  in  openings  or  retroperitoneal  hernia  is  also  a  serious  condition. 
In  Gibson's  series  of  34  cases,  62  per  cent  died.  During  the  past  eight  years, 
however,  of  15  cases  found  in  the  hterature,  10  were  cured  by  operation,  including 
one  of  my  own. 

A  cancerous  growth  is,  unhappily,  one  of  the  commonest  forms  of  acute 
intestinal  obstruction.  At  St.  Thomas's  Hospital,  out  of  137  such  cases,  65  per 
cent  died.  The  growth  in  the  great  majority  was  situated  in  the  sigmoid  or 
rectum.  In  Paul's  series  of  24  private  cases,  treated  by  colostomy,  9  were  fatal. 
Of  23  cases  at  the  Bristol  Royal  Infirmary  all  suffering  from  acute  obstruction, 
and  excluding  patients  with  a  band,  hernia,  gall-stone,  volvulus,  or  intussuscep- 
tion, 6  died  ;  these  were  nearly  all  suffering  from  cancer  of  the  bowel  treated  by 
colostomy.     (For  further  progress  of  the  cases,  see  Colon,  Carcinoma  of.) 

The  Prognosis  in  Individual  Cases.^There  is  a  remarkable  sex  difference  ; 
the  mortality  in  women  is  only  33  per  cent,  against  54  per  cent  in  males  (Gibson). 
This  is  difficult  to  explain. 

The  principal  factors  in  judging  the  prognosis  in  any  particular  case  are 
(i)  The  time  of  operation  ;  (2)  The  nature  and  frequency  of  the  vomiting  ;  and 
(3)  The  presence  or  absence  of  gangrene  when  the  abdomen  is  opened. 

1.  The  importance  of  early  operation  has  already  been  emphasized.  The  first 
two  days  are  relatively  favourable  ;  after  the  fifth  day  the  chances  are  against 
survival. 

2.  The  nature  and  frequency  of  the  vomiting  is  very  important.  A  high-up 
obstruction,  near  the  duodenum,  causes  very  frequent  and  urgent  vomiting, 
without  much  distention  of  the  abdomen,  and  the  vomit  becomes  foul  but  not 
fscal  ;  these  cases  are  very  fatal  unless  operated  on  early.  When  the  obstruc- 
tion is  low  down  in  the  colon  or  rectum,  vomiting  is  late  and  infrequent,  and 
there  is  more  time  before  the  patient  passes  bej^ond  the  reach  of  surgical  help. 
If  the  vomit  becomes  foul,  the  outlook  is  grave  ;   if  fscal,  it  is  almost  hopeless. 

3.  //  a  gangrenous  area  is  found  at  the  operation,  the  chances  of  recovery  are 
small,  but  not  hopeless. 

A  '  chesty  '  patient,  or  one  suffering  from  grave  toxaemia,  is  not  likely  to  be 
saved,  and  the  advent  of  peritonitis  is  practically  a  death-warrant. 

The  method  of  giving  the  anaesthetic  and  of  conducting  the  operation  counts 
for  something.  If  there  is  incessant  vomiting  or  bronchitis,  intraspinal  or  local 
anaesthesia  is  probably  safer.  It  is  very  important  to  operate  quickly,  and  to 
empty  the  distended,  paralyzed  coils  of  bowel  by  Moynihan's  tube  or  some 
similar  device.  Physostigmine  salicylate  and  pituitary  extract  will  probably 
reduce  the  mortality  a  little  by  averting  post-operative  intestinal  palsy. 

References.— Gibson,  Ann.  Surg.  1900,  xxxii,  486;  Treves,  Intestinal  Obstruction, 
1899  ;  Moynihan,  Abdominal  Operations,  1906  ;  Finsterer,  Arch.  f.  klin.  Chir.  19 12, 
010  ;  Paul,  Brit.  Med.  Jour.  1912,  ii,  172  ;  Jankowski,  Deut.  Zeits.  f.  Chir.  1913,  Sept.  ; 
^'lakins,  Burghard's  System  of  Operative  Surgery,  ii,  521.  A.  Rendle  Short. 

INTESTINE,  INJURIES  OY.—{See  Abdominal  Injuries.) 

INTRACRANIAL  COMPLICATIONS  OF  EAR  DISEASE.— It  is  stated"  by 
Haseler  that  of  81,684  cases  of  suppurative  otitis  media,  116  died  of  various 
intracranial  complications  (lateral  sinus  thrombosis  48,  meningitis  40,  abscess 
28),  a  percentage  of  about  0-14.  Some  London  figures  agree  with  this.  The 
risk,  therefore,  is  about  i  in  700. 

It  is  very  difficult  to  find  in  the  literature  a  sufficient  number  of  reliable  records 
by  which  we  may  judge  the  prognosis  of  these  affections.  Some  statistics  arc 
altogether  too  favourable  ;    in  others    a  few  successes  have   been  reported  and 


244 


INDEX     OF     PROGNOSIS 


many  failures  overlooked.  It  must  be  remembered  that,  in  practice,  two  intra- 
cranial complications  often  exist  together,  and  obscure  both  the  diagnosis  and 
the  prognosis. 

Lateral  Sinus  Thrombosis. — Apart  from  operation,  these  patients  nearly  all 
die  of  pyaemia  or  meningitis,  the  duration  of  life  varying  from  two  to  six  weeks. 
Natural  recovery  does  occasionally  take  place,  but  it  is  rare  ;  the  writer  has  seen 
one  case.  The  prognosis  depends  upon  early  operation,  but  patients  may  occa- 
sionally be  saved  even  after  abscesses  have  formed  in  the  lungs. 

According  to  Hunter  Tod,  about  a  third  of  the  patients  operated  on  recover. 
Macewen's  results  were  much  better  than  this  (20  out  of  28).  At  the  Bristol 
Royal  Infirmary,  5  patients  out  of  1 1  recovered  ;  some  of  the  fatal  cases  had  an 
abscess  as  well.  No  doubt  earlier  diagnosis  would  improve  the  prospects  very 
much. 

I  have  interviewed  three  patients  some  years  afterwards.  One  was  quite 
cured  ;  another  suffered  for  months  from  pyaemia,  and  then  recovered  except 
for  otorrhcea  ;   the  tliird  complained  of  persistent  giddiness,  due  to  labyrinthitis. 

Extradural  Abscess. — All  five  of  Macewen's  cases  recovered  ;  but  in  practice 
many  of  these  patients  die,  in  spite  of  operation. 

Abscess  of  the  Cerebellum  or  Temporosphenoidal  Lobe. — Unfortunately  the 
difficulties  of  diagnosis,  especially  of  cerebellar  abscess,  are  very  great.  The 
classical  signs,  nystagmus,  ataxia,  or  atonia,  are  very  frequently  absent  ;  optic 
neuritis  is  inconstant  ;  and  the  subnormal  temperature  is  only  present  in  about 
half  the  cases.  At  the  Bristol  Royal  Infirmary  during  ten  years,  6  cases  of 
cerebellar  abscess  were  missed,  but  of  8  cases  of  temporosphenoidal  abscess  a 
successful  diagnosis  was  made  in  every  instance. 

In  our  experience,  the  main  point  in  the  prognosis  is  to  operate  within  three 
days  of  the  onset  of  drowsiness  (not  coma).  Of  ^  cases  so  treated,  3  recovered  ; 
later  than  the  third  day  none  recovered. 

The  prognosis  after  operation  is  very  much  better  in  temporosphenoidal  than 
in  cerebellar  abscess.  Once  again  Macewen's  results  are  much  better  than  those 
ordinarily  obtained  ;  but  according  to  the  statistics  of  Henke  and  of  the  Bristol 
Royal  Infirmary,  from  a  third  to  half  of  the  patients  may  be  saved  in  cerebral 
cases,  and  a  quarter  or  less  (7  out  of  28  in  Politzer's  clinic)  of  the  sufferers  from 
cerebellar  abscess.  Of  100  patients  treated  at  the  London  Hospital  during  ten 
years,  20  temporosphenoidal  and  10  cerebellar  cases  recovered  ;  probably  this 
is  abnormally  bad.  Milligan's  series  of  27  operations  for  cerebellar  abscess  at 
Manchester  during  ten  years  is  very  gratifying,  17  being  saved  and  10  djdng. 

After  operation  the  patient  may  remain  in  a  drowsy  state  for  days,  and  yet 
recover  if  the  pulse  and  temperature  are  normal  ;  but  symptoms  often  return 
and  end  fatally. 

If  the  patient  recovers,  there  is  some  fear  of  persistent  liability  to  convulsions  ; 
the  writer  has  seen  one  such  case. 

Mortality  in  Cases  of  Intracranial    Complications  of  Ear  Disease 
treated   by  operation. 


Lateral  Sinus 
-   Thrombosis 

Ceeebeal  Abscess 

Cerebellak  abscess 

Cases 

Deaths 

KecoY- 
eries 

Cases 

Deaths 

Eeoov- 
eries 

Cases 

Deaths 

Recov- 
eries 

Macewen  .         -         -        - 
Henke  -    .... 
Bristol  Royal  Infirmary  - 
Politzer's  Clinic 
Milligan     - 

28 
11 

8 
6 

20 
5 

9 

37 
10 

I 
20 

7 

8 

17 

3 

4 
10 

4 
28 
27 

0 

9 

4 

21 

10 

4 
1 
0 

7 
17 

INT  USS  USCEPTION 


245 


Meningitis. — The  onset  of  evidence  of  meningitis  (head-retraction,  Kernig's 
sign,  nerve-palsies,  irregular  fever)  is  usually  a  death  warrant,  but  a  few  cases 
have  undoubtedly  been  saved.  Macewen  operated  on  6  out  of  12  cases  where 
there  was  intracranial  meningitis  only,  and  saved  them  all  ;  only  i  out  of  6 
patients  with  cerebrospinal  meningitis  recovered.  The  writer  has  seen  a  case 
saved  by  operation  and  drainage,  combined  with  repeated  lumbar  puncture. 
Urotropine  probably  helps. 

References. — Macewen,  Pyogenic  Diseases  of  the  Brain  and  Spinal  Cord  ;  Neumann, 
Cerebellar  Abscess  (Lake's  translation)  ;  Hunter  Tod,  "  Intracranial  Complications  of 
Ear  Disease,"  Burghard's  System  of  Operative  Surgery,  iv,  429  ;  Milligan,  Brit.  Med.  Jour. 
1914,  ii,  833.  ^.  Rendle  Short. 

INTUSSUSCEPTION.— It  will  be  necessary  to  consider,  first,  the  acute 
intussusceptions,  usually  of  children  ;  and,  secondly,  the  chronic  intussuscep- 
tions of  adults. 

Acute  Intussusception. — There  is  a  natural  cure  of  intussusception  by 
sloughing  of  the  intussusceptum.  It  is  very  difficult  to  arrive  at  any  idea  of 
its  true  frequency.  Wiggins  (quoted  by  Childe)  puts  the  spontaneous  cures  at 
approximately  i  per  cent ;  but  there  is  always  the  probability  that  such  a 
curiosity  would  turn  up  witk  undue  frequency  in  the  medical  literature.  The 
main  point  is  that  it  is  an  event  of  excessive  rarity  in  infancy  ;  only  8  per  cent 
of  the  recorded  cases  were  in  children  under  eight  years  of  age.  In  adults  it  is 
not  so  very  infrequent,  and  the  slough  may  come  away  several  weeks  afterwards. 
A  few  cases  die  (said  to  be  3  per  cent)  even  after  passage  of  the  slough.  Apart 
from  this  very  exceptional  occurrence,  the  average  length  of  life,  in  infants,  is 
about  three  days.  Cases  have  died  within  nine  hours.  Three  or  four  reports 
in  the  literature  appear  to  suggest  that  an  intussusception  may  in  very  rare  cases 
reduce  itself  spontaneously. 

Cure  by  Injection  of  Water  is  now  attempted  by  very  few  surgeons,  because 
it  often  fails  even  in  early  cases,  and  it  is  impossible  to  tell  for  inany  hours  whether 
it  has  succeeded  or  not,  so  that  the  necessary  operation  may  be  dangerously 
delayed.  Clubbe,  of  Sydney,  tried  it  in  138  cases,  but  it  was  only  successful  in 
14  of  these. 

In  Copenhagen,  it  is  apparently  the  routine  to  treat  cases  of  intussusception 
by  injection  of  water  under  an  ansesthetic,  even  two  or  three  days  after  the 
onset.  Koch  and  Oerum  have  furnished  details  of  397  cases,  60  per  cent  under 
twelve  months  old,  treated  between  1880  and  1909.  One  to  two  pints  are 
injected  with  an  enema  syringe,  and  then  taxis  is  used.  Deep  anassthesia  is 
required.  In  2  cases  the  bowel  was  ruptured.  In  the  worst  cases  only,  a  pri- 
mary operation  is  performed.  If  the  injection  fails,  a  secondary  operation  is 
undertaken. 

Results  of  Treatment  in  Copenhagen  by  Injection  under  Chloroform. 


Cases 

Cured  by  injection 

Failed  and  had  operation 

Total 
Cured 

Total 

Lived 

Died 

Died 

Under  12  months 
Over   12  months 

187 
114 

87 
(i5 

13 

24 

39 
10 

100 
89 

87 

25 

Total 

301 

152 

37 

55 

189 
=  03  % 

112 
=  37% 

Set  forth  as  they  are  in  the  authors'  tables,  the  results  of  injection  of  course 
appear  to  be  much  better  than  those  of  operation.     We  have  recalculated  the 


246 


INDEX     OF     PROGNOSIS 


figures  according  to  the  data  furnished,  so  as  to  be  able  to  compare  the  conse- 
quences with  those  of  the  English  school  of  practice. 

It  will  be  observed,  first,  that  about  half  the  cases  are  capable  of  cure  by 
injection  and  taxis  under  an  anaesthetic,  but  secondly,  that  the  eventual  results 
are  not  so  good  as  the  figures  furnished  by  St.  Bartholomew's  Hospital  or  by 
Clubbe.  When  it  is  remembered  that  the  injection  method  was  only  used  for 
the  more  favourable  type  of  patients,  and  that  in  65  graver  cases  primary  opera- 
tion was  performed,  it  is  clear  that  the  Danish  figures  do  not  establish  a  powerful 
argument  for  bloodless  measures.  It  must  further  be  borne  in  mind  that 
perhaps  a  few  recoveries  were  not  cases  of  intussusception  at  all.  If  it  is  pos- 
sible to  administer  an  anaesthetic,  it  is  usually  also  possible  to  operate. 

Reduction  of  the  Intussusception  by  Operation  is  the  routine  treatment. 
Judging  by  the  published  statistics,  about  two-thirds  of  the  cases  recover  and 
one-third  die.  Records  are  given  in  the  table  of  59  children  treated  by  reduction 
at  St.  Bartholomew's  Hospital  from  1901  to  1911,  124  cases  operated  on  by 
Clubbe,  and  46  cases  of  all  ages  similarly  treated  at  the  Bristol  Royal  Infirmary 
from  1903  to  1912.  The  St.  Thomas's  Hospital  figures  are  less  favourable,  but 
they  go  back  to  1887. 


Table  of  Cases  of  Acute  Intussusception  treated  by 
Laparotomy   and    Reduction. 


St.  Bartholomew's  Hospital* 

Clubbet 

Bristol   Royal    Infirmaryf    - 

St.  Thomas's  Hospitalf 


59 
116 

46 
202 


46  =  78% 

83  =  73% 

28  =  61% 

109  =  54% 


13  =  22% 

00    2tD    /Q 

18  =  39% 
93  =  46% 


60 
73'3 
57-5 
26-6 


•Children  only.        tAU  ages. 

The  success  of  treatment  depends  principally  upon  early  diagnosis.  Childe 
quotes  123  Glasgow  cases,  of  which — 

Operation  within     6  hours  gave  . .      60      per  cent  cured. 

6  to  12  hours  gave 
,,  ,.      12  to  24        ,, 

,,  .,      24  to  48        ,,         ,, 

Acute  cases  operated  on  after  forty-eight  hours  nearly  all  die,  but  there  is  a  more 
chronic  type,  in  which  the  results  are  fairly  favourable;  thus,  8  out  of  12  such  at 
St.  Bartholomew's  recovered.  The  higher  death-rate  within  the  first  six  hours 
than  in  the  next  six -hourly  period  is  a  common  phenomenon  in  the  records  of 
abdominal  surgery  ;  it  must  not  be  used  as  a  plea  for  delay,  as  it  means  no  more 
than  that  the  ultra- acute  cases  are  soonest  diagnosed. 

Prognosis  in  older  persons  is  worse  than  in  infants  ;  thus,  in  the  St. 
Bartholomew's  Hospital  series,  of  the  patients  over  two  years,  9  out  of  19  died, 
and  of  those  under  two,  only  24  out  of  68. 

Treatment  by  Resection  is  a  last-resort  method,  and  usually  leads  to  a  fatal 
result.  There  are  a  few  instances  of  successes  on  record.  At  the  discussion  in 
1910  at  the  Royal  Society  of  Medicine,  4  cures  were  mentioned,  2  aged  two  and 
four  respectively,  at  the  Queen's  Hospital  for  Children,  and  i  aged  seven  months 
at  Great  Ormond  Street,  under  spinal  analgesia.  Clubbe  reports  a  recovery  in  a 
child  of  eleven  months  ;  7  other  resected  cases  all  died.  The  writer  has  seen  a 
recovery  in  a  young  man  with  acute  intussusception,  in  whom  five  feet  of  gut 
were  resected  by  Hey  Groves.  Four  out  of  24  resection  cases,  all  patients  over 
a  year  old,  recovered  in  the  Copenhagen  series. 


JAWS,     TUMOURS     OF  247 

Relapse  is  uncommon.  The  only  case  which  has  come  under  the  writer's 
notice  is  one  in  which  an  appendicostomy  was  performed,  partly  for  feeding 
purposes,  and  partly  to  prevent  relapse  ! 

Prognosis  in  Individual  Cases  depends  largely  upon  the  length  of  time  before 
treatment  is  instituted  ;  over  twenty-four  hours  turns  the  chances  against  the 
child.  Much  vomiting,  listlessness  and  lack  of  interest,  and  a  depressed  fonta- 
nelle  are  all  grave  signs.  There  does  not  appear  to  be  much  evidence  that  one 
anatomical  variety  of  acute  intussusception  is  more  dangerous  than  another. 

Chronic  Intussusception. — This  rare  disease  is  usually  of  grave  import,  because 
it  is  likely  to  be  diagnosed  late,  and  reduction  will  probably  be  impossible. 
Of  6  cases  treated  by  resection  at  St.  Bartholomew's  Hospital  (1873-1908),  i 
recovered  and  5  died. 

Maxwell,  of  Formosa,  reports  6  cases  there,  whereof  3,  treated  by  lateral  anas- 
tomosis, recovered,  and  3  died.  The  writer  has  seen  i  case  which  was  resected, 
but  died.  It  would,  therefore,  appear  to  be  better  to  leave  the  intussusception 
and  do  a  short-circuiting  lateral  anastomosis. 

References. — Clubbe,  On  Intussusception;  Childe,  "Diseases  of  Children,"  Proc. 
Roy.  Soc.  Med.  1910,  vol.  iii,  pt.  i,  165;  Eccles,  St.  Bart.'s  Hosp.  Rep.  1911,  97  i 
Maxwell,  Ibid.  1908,  153;  Koch  and  Oerum,  Edin.  Med.  Jour.  1912,  ix,  227;  Makins, 
Burghard's  System  of  Operative  Surgery,  Vol.  ii,  521.  A.  Rendle  Short. 

ISCHiEMIC  CONTRACTURE.— (See  Muscular  Atrophies.) 

JAWS,  TUMOURS  OF.— Although  there  is  no  reason  to  believe  that  there 
is  any  difference  between  the  prognosis  of  growths  of  the  upper  and  of  the  lower 
jaws,  we  shall  follow  the  example  of  most  writers,  and  discuss  them 
separately,  at  least  as  far  as  malignant  disease  is  concerned. 

Epulis. — There  is  some  difference  of  opinion  as  to  what  is  meant  by  a  '  simple  ' 
epulis.  Under  this  name  the  older  writers  described  what  they  took  to  be  a 
fibroma.  According  to  Eve,  out  of  17  cases  microscoped  at  the  London  Hospital, 
2  were  fibrosarcoma,  8  were  myeloid,  and  7  were  granulation  tissue  ;  he  doubts, 
therefore,  whether  there  is  any  such  thing  as  a  fibrous  epulis.  In  Kiihner's 
series,  out  of  30  microscoped  there  were  2  fibromas  ;  of  the  remainder,  20  proved 
to  be  myeloid,  7  sarcoma,  and  i  granulation  tissue.  Both  these  statistics  refer  to 
surgical  clinics  ;  in  the  reports  of  dental  clinics,  where  the  smaller  and  more 
chronic  growths  are  likely  to  be  seen,  fibrous  epulis  is  much  commoner. 

If,  then,  we  take  epulis  to  mean  a  tumour  of  the  gum,  the  majority  of  the 
cases  will  be  myeloid  or  fibrosarcoma.  Nevertheless,  the  end-results  appear 
to  be  very  satisfactory  if  an  efficient  operation  is  done  in  the  first  place — that 
is,  if  a  small  margin  of  healthy  bone  is  removed  together  with  the  growth.  It  is 
not  usually  necessary  to  divide  the  lower  jaw,  or  to  encroach  on  the  antrum, 
but  even  if  this  has  to  be  done,  as  in  a  case  of  the  writer's,  it  is  remarkable  how 
the  antrum  fills  up  in  time,  so  that  a  small  addition  to  a  dental  plate  closes  it 
effectually.     The  operation  has  almost  no  mortality. 

End-results  of  Operation  for  Epulis. 


Keporter 

Cases 

Died  of  operation 

Relapsed 

Eve,  London  Hospital 
Kuhner,  TiJbingen  clinic 

:50 
7i) 

0 
0 

6 

7 

Of    the   7    recurrences   at   the  Tiibingen   clinic,    5   were   cured   by   a   second 
operation ;      in    2    patients    death    followed     recurrence.      The     microscopical 


248 


INDEX     OF     PROGNOSIS 


findings  in  30  of  the  cases  are  quoted  above.  We  have  evidence,  therefore,  that 
even  a  so-called  niaUgnant  epuhs  can  usually  be  cured  by  a  small  operation — 
namely,  removal  of  the  portion  of  the  alveolar  process  containing  it. 

Tumours  of  the  Upper  Jaw. — Coming  now  to  the  consideration  of  tumours 
involving  the  body  of  the  jaw,  or  growing  from  the  antrum,  we  find  a  very  much 
graver  state  of  affairs.  There  are  a  number  of  published  records  on  which  to 
base  an  opinion  as  to  the  prognosis,  mostly  German  and  derived  from  a  study 
of  the  end-results  in  various  university  chnics. 

These  growths  are  nearly  all  cancer  or  sarcoma,  and  apart  from  operation  are 
as  a  rule  fatal  in  from  one  to  three  years.  The  usual  treatment  is  by  partial  or 
complete  removal  of  the  maxilla.  Gland-involvement  appears  to  be  late  and 
infrequent,  so  that  it  is  not  usually  necessary  to  clear  the  lymphatic  area  in  the 
neck. 

The  mortality  of  removal  of  the  superior  maxilla  is  undoubtedly  high.  The 
figures  for  three  London  hospitals  from  18S6  to  1897  give  a  death-rate  of  only 
12-6  per  cent  in  127  cases,  but  this  probably  includes  a  good  many  partial 
operations.  The  carefully  described  records  of  Eve,  Butlin,  and  the  Gottingen 
clinic  under  Koenig,  running  up  to  1S97,  are  more  worthy  of  confidence,  and 
these  show  a  mortality  of  i5-6,  28'5,  and  32  per  cent  respectively.  Eve's  figures 
are  more  recent  (1907),  and  he  practises  a  preliminary  laryngotomy.  Kronlein's 
estimate  from  the  hterature  since  1875  is  probably  the  most  reUable  figure  we 
have  for  present-day  surgery,  and  we  therefore  conclude  that  the  mortality  is 
about  one  in  four  or  five.  A  partial  resection  is,  of  course,  less  dangerous.  The 
fatalities  are  usually  from  pulmonarj^  comphcations. 

Operation-mortality    and    End-results    of    Removal 
OF    Superior    Maxilla  for  Malignant  Growths. 


Reporter 

Cases 

! 
Operation- 
mortality 

per  cent 

Cases 
foUowed 

Cured 

Recurred 

Eve           -        -  '     - 
Butlin       -        -        -        - 
Kronleia  (literature) 
Three  London     hospitals 
Greifswald  clinic 
Estlander's  clinic     - 
Gottingen  clinic 
BerUn  clinic 

Von  Bergmann's  clinic  - 
Erlangen  clinic 

12 

14 
158 
127 

72 

16-6 

28-5 
21-5 
12-6 

32 

10 

12 

1  49 

i  47 
1  21 

17 

5 
0 

2 
16 

5 
6 

1 

5 

17 
10 
33 

42 
15 
16 

Total 

173 

85 

(or  22 
per  cent 

138 

(or  78  per 
cent* 

Turning  now  to  the  prospects  of  cure,  we  find  here  also  plenty  of  room  for 
improvement.  Buthn  records  10  cases,  of  which  5  recurred,  2  were  alive  and 
well  less  than  three  years,  and  3  were  aUve  and  well  more  than  three  years 
afterwards — but  in  one  of  these  the  diagnosis  was  doubtful  ;  two  patients  ^vitl^ 
epithehoma  appeared  to  be  cured,  though  the  orbital  plate  was  left.  In  the 
Greifswald  chnic  no  cases  out  of  17,  at  the  Erlangen  chnic  i  out  of  16,  and  in 
Estlander's  clinic  2  out  of  12,  were  successful.  At  von  Bergmann's  chnic  13  cases 
of  epithehoma  were  operated  on  without  success  ;  but  of  8  cases  of  sarcoma, 
6  were  apparently  cured.     In  the  Berlin  chnic  only  5  out  of  47  were  cured  by 


JOINTS,     INJURIES     OF  249 


a  total  resection  ;  but  when  partial  removal  could  be  practised,  half  the  patients 
were  cured.  The  most  detailed  figures  available,  albeit  rather  old  now,  are  from 
the  Gottingen  cUnic  up  to  1S97,  where,  of  cases  recovering  from  the  operation, 
16  out  of  49  were  apparently  cured  ;  of  these,  14  were  followed  over  three  years 
(up  to  eighteen  years  in  one  instance),  and  2  less  than  three  years.  The  micro- 
scopical report  on  these  16  growths  showed  8  epithelioma,  4  myeloid,  3  sarcoma, 
and  I  endothelioma.  In  the  cancerous  cases  the  orbital  plate  was  always  removed, 
because  it  was  found  that  recurrence  followed  if  tliis  was  not  done.  In  non- 
cancerous cases  the  plate  was  sometimes  left  ;  of  13  such,  i  died  of  the  operation, 
7  recurred,  and  5  were  apparently  cured  (2  under,  3  over,  three  years). 

We  may  conclude,  therefore,  that  in  cases  of  malignant  disease  calling  for 
removal  of  the  upper  jaw,  about  i  in  5  is  likely  to  be  cured.  The  cancer  cases 
are  more  serious  than  those  with  sarcoma  or  myeloid.  In  the  great  majority, 
recurrence  takes  place  within  four  months,  and  death  in  a  year. 

A  serious  deformity  is,  of  course,  left  by  the  operation,  and  an  artificial  jaw 
will  be  required.  Also,  if  the  orbital  plate  is  removed,  the  eye  may  drop  and 
cause  diplopia. 

To  summarize,  we  may  estimate  that  of  100  patients  with  growths  of  the 
upper  jaw  treated  by  operation,  about  22  will  die  of  the  surgical  procedure,  and 
about  16  will  obtain  lasting  cure — rather  more  in  the  sarcomatous  group  and 
rather  less  in  the  cancerous. 

Tumours  of  the  Lower  Jaw.^ — The  material  for  judging  the  prognosis  in  this 
variety  of  malignant  disease  is  old  and  inadequate.  Butlin  has  collected  the 
records  of  60  cases  of  excision  of  the  lower  jaw,  with  8  fatalities.  The  growths 
which  call  for  the  operation  are  periosteal  sarcoma,  myeloid  sarcoma,  and 
epithelial  odontome.  Of  11  cases  of  periosteal  sarcoma  collected  from  the 
literature  by  Butlin,  i  was  well  nearly  three  years  after,  i  died  of  pneumonia 
within  a  year,  and  9  recuiTcd.  Of  43  cases  of  m^^eloid,  8  died  of  the  operation, 
2  recurred,  30  were  not  followed  up,  and  13  were  '  cured  ' — but  only  4  of  these 
were  followed  three  years. 

Here  again,  grave  deformity  follows  the  operation,  but  it  can  be  remedied  by 
the  application  of  a  dental  prosthesis,  even  to  such  a  degree  that  the  patient 
may  be  able  to  bite  an  apple  ;    or  a  piece  of  rib  may  be  grafted  in. 

References. — Eve,  Brit.  Med.  Jour.  1907,  i,  1525  ;  ButUn,  The  Operative  Surgery 
of  Malignant  Disease,  2nd  ed.,  1900  ;  Fagge,  "Diseases  of  the  Jaws,"  Burghard's  System 
of  operative  Surgery.  ^_  ^^^^^^  ^hort. 

JOINTS,  INJURIES  OF  {see  also  Knee- Joint,  Injuries  of;  Congenital 
Dislocation  of  Hip). — We  shall  treat  the  subject  under  three  headings  :  (i) 
Sprains  ;    (2)  Dislocations  ;    and  (3)  Perforating  wounds. 

I.  Sprains. — -An  ordinary  sprained  ankle,  wrist,  or  other  joint,  given  proper 
treatment  such  as  rest,  cold,  and  compression  at  first,  and  massage  and  move- 
ments later,  will  recover  completely  in  a  month  or  two.  Trifling  injuries  will 
be  well  in  a  correspondingly  shorter  time.  There  are,  however,  certain  excep- 
tions to  the  rule. 

The  first  of  these  is  the  sprain-fracture.  Not  at  all  an  uncommon  injury  is  a 
so-called  sprained  wrist  accompanied  by  a  fracture  of  one  of  the  carpal  bones, 
notably  the  scaphoid.  This  accounts  for  a  large  proportion  of  those  cases  in 
which  pain,  stiffness,  or  discomfort  persists  for  j^ears.  The  diagnosis  is  made, 
even  after  a  long  interval,  by  skiagram.  If  recognized  early,  something  may  be 
done  to  avert  the  prolonged  disability,  by  advising  against  all  movement,  and 
fixing  the  wrist  in  a  splint  for  a  month,  taking  care  to  reduce  any  deformity,  if 
necessary  by  open  operation. 


250  INDEX    OF    PROGNOSIS 

A  second  obstacle  in  the  way  of  a  confident  prognosis  is  the  possibiUty  of  the 
development  of  some  form  of  arthritis.  Rarely,  tuberculous  joint-disease  may 
follow  the  injury.  More  often,  and  especially  in  the  shoulder,  a  traumatic 
arthritis  may  make  itself  evident  a  few  weeks  after  the  sprain  ;  there  is  marked 
teinderness  over  the  coracoid,  and  limitation  of  movement  in  all  directions.  It 
is  very  important  not  to  attempt  to  treat  this  condition  by  forcible  movement, 
or  it  may  go  on  to  permanent  incapacity.  The  proper  treatment  is  rest.  But 
in  any  case  the  trouble  is  likely  to  remain  for  a  long  time,  and  there  will  prob- 
ably be  some  loss  of  range  of  movement. 

A  third  source  of  disappointment  is  the  formation  of  adhesions.  This  can  and 
ought  to  be  prevented  by  early  recognition  of  the  nature  of  the  limitation  of 
movement.  It  calls  for  exercises,  and  if  necessary  the  breaking  down  of  the 
adhesions  under  gas.  In  the  case  of  the  shoulder  joint,  there  is  no  tenderness 
on  direct  pressure  over  the  coracoid,  and  movements  are  more  painful  in  one 
direction  than  in  another.  This  distinguishes  it  from  the  arthritis  just  de- 
scribed. No  joint  ought  to  be  moved  whilst  there  is  still  synovitis,  heat,  or 
redness  in  or  about  it. 

Given  early  diagnosis,  including  a  skiagram,  and  proper  treatment,  the  sur- 
geon is  able  to  give  a  fairly  accurate  prognosis,  except  for  the  unknown  factor 
of  arthritis  ;  this  cannot  be  foretold,  but  it  may  only  too  probably  occur  if  the 
patient  is  known  to  be  '  gouty  '  or  '  rheumatic  '  in  the  old-fashioned  sense. 

Aged  persons  usually  do  not  recover  well. 

2.  Dislocations. — Apart  from  treatment,  a  dislocation  is  bound  to  lead  to  a 
great  deal  of  disability  ;  but  in  the  case  of  the  shoulder  joint,  in  young  adults 
at  any  rate,  a  very  fair  degree  of  usefulness  is  often  recovered. 

Late  excision  for  unreduced  dislocation,  or  operative  replacement,  gives  results 
much  less  favourable  than  those  of  immediate  bloodless  reduction,  but  some- 
times a  very  fairly  useful  joint  is  obtained,  and,  at  the  shoulder,  rotation  even 
may  be  preserved.  Scudder  and  Barney^  report  ii  cases  of  unreduced  disloca- 
tion of  the  shoulder  treated  by  excision  and  examined  several  years  afterwards. 
Of  these,  rather  more  than  half  obtained  a  fair,  but  not  perfect,  result.  There 
was  always  marked  limitation  of  movement.  The  best  success  was  obtained 
in  a  child. 

Immediate  reduction  by  manipulation  is,  of  course,  the  best  treatment  when 
possible,  and  in  the  majority  of  cases  leads  in  the  course  of  two  or  three  months 
to  a  perfect  cure,  at  any  rate  in  patients  under  thirty,  and  given  proper  treat- 
ment after  reduction.  Of  i6  adult  cases  of  dislocation  of  the  shoulder  investi- 
gated as  to  the  end-results  at  the  London  Hospital,^  lo  obtained  a  good  result, 
5  fair,  and  i  bad.  Elbow  cases  in  children  may  be  said  to  do  very  well ;  in 
middle-aged  or  elderly  people  there  will  probably  be  some  permanent  limitation 
of  movement. 

A  too  favourable  prognosis,  however,  has  to  be  guarded  against,  because  each 
of  the  complicating  factors  which  we  have  passed  in  review  as  spoiling  the  pros- 
pects of  a  cure  after  a  sprain  may  also  be  operative  after  a  dislocation.  There 
are  two  other  unfavourable  conditions  to  be  added  to  the  list  :  first,  after  some 
dislocations,  and  especially  those  of  the  hip,  the  muscles  may  be  so  torn  as  to  lead 
to  permanent  lameness  ;  and  second,  dislocations  of  the  shoulder,  jaw,  patella, 
and  clavicle  sometimes  show  a  remarkable  tendency  to  relapse. 

In  the  case  of  the  clavicle  and  patella  relapse  is  not  very  serious,  but  it  may 
become  a  great  nuisance  to  the  patient  if  the  jaw  or  the  shoulder  keeps  on  getting 
out  of  joint.  It  is  related  that  a  certain  famous  barrister  was  subject  to  the 
former  affliction,  and  used  sometimes  to  be  taken  when  in  the  act  of  addressing 
'  my  lord  '  or  the  jury  :  onwhicn  occasions  he  used  to  envelop  his  face  in  a  hand- 


KIDNEY,     NEW    GROWTHS     OF  251 

kerchief  as  though  overcome  by  emotion,  and  hurry  from  the  court.  He  acquired 
the  reputation  of  being  full  of  sympathy  for  the  woes  of  his  clients. 

Recurrent  dislocation  of  the  shoulder  is  prone  to  occur  in  epileptics.  Thomas^ 
has  recently  published  a  series  of  iS  shoulders  treated  by  taking  a  reef  in  the 
capsule.  In  13  of  these  a  cure  was  obtained  ;  in  3  others  a  further  dislocation 
occurred,  but  only  as  a  result  of  severe  injury,  such  as  in  wrestling  ;  in  2  cases 
the  operation  was  not  successful.  Thomas  makes  use  of  a  posterior  approach 
to  the  joint. 

3.  Perforating  Wounds. — Given  immediate  diagnosis,  and  thorough  cleansing 
and  drainage  within  a  few  hours,  more  or  less  perfect  recovery  can  usually  be 
obtained,  with  at  worst  a  certain  amount  of  stiffness. 

Many  wounds  of  joints  do  not  lead  to  suppuration,  and  the  prognosis  is  then 
approximately  that  of  a  sprain.  But  if  septic  arthritis  makes  its  appearance — 
usually  by  the  third  or  fourth  day — the  outlook  as  regards  the  joint  is  grave 
indeed,  and  even  the  patient's  life  may  be  in  jeopardy.  Repeated  incisions  for 
drainage  may  fail  to  give  relief,  pyaemia  often  supervenes,  and  at  last  in  despair 
both  patient  and  surgeon  are  glad  to  end  the  struggle  by  an  amputation.  If 
this  is  avoided,  bony  ankylosis  will  probably  take  place,  with  or  without  dis- 
placement. 

References. — ^Scudder  and  Barney,  ^ mm.  Surg.  1909,  xlix,' 696  ;  ^Warren,  Lancet, 
1909,  ii,  138,  2ig  ;  .^Thomas,  Surg.  Gyn.  and  Obst.  1914,  xviii,  107.         ^,  Rendle  Short. 

JOINTS,  TUBERCULOUS. — [See  Arthritis,  Tuberculous.) 

KALA-AZAR.— (5ee  Tropical  Fevers.) 

KIDNEY,  INJURIES  OF.— (See  Abdominal  Injuries.) 

KIDNEY,  MOVABLE.— (See  Movable  Kidney.) 

KIDNEY,  NEW  GROWTHS  OF. — The  following  factors  are  important  in 
considering  the  prognosis  of  renal  new  growths  : — 

I.  The  Malignancy  of  Kidney  Growths. — A  small  number  of  benign  tumours 
have  been  described  in  the  kidney.  Some  of  these,  however,  are  known  to 
develop  malignant  characters  at  a  later  date.  The  v/riter  has  removed  a 
kidney,  the  seat  of  extensive  malignant  growth,  from  a  patient  who  for  over 
five  years  had  passed  in  the  urine  portions  of  papillomatous  growth  from  the 
renal  pelvis  which  were  examined  by  an  eminent  pathologist  and  pronounced 
non-malignant.  Cases  of  papilloma  of  the  renal  pelvis  are  on  record  where 
symptoms  had  been  present  for  twenty  years,  and  nine  and  a  half  years,  before 
operation.  The  writer  also  knows  of  a  case  where  a  growth,  after  removal, 
was  published  as  an  adenoma  of  the  kidney  ;  the  patient  afterwards  developed 
multiple  bony  metastases,  from  which  he  died  within  two  years.  The  number 
of  growths  that  remain  benign  must  be  quite  insignificant. 

All  new  growths  of  the  kidney  should  therefore  be  looked  upon  cUnically 
as  malignant.  Some  variation  is  said  to  exist  in  regard  to  the  relative 
malignancy  of  the  different  forms  of  mahgnant  growths  of  the  kidney,  and  an 
opinion  based  on  this  might  be  given  after  removal  and  examination  of  the 
kidney.  Hypernephroma  is  believed  to  be  less  rapid  in  its  course  as  compared 
with  sarcoma  and  carcinoma  of  the  kidney.  It  is,  however,  unwise  to  make 
definite  statements  based  upon  the  liistological  varieties.  The  new  growths 
grouped  under  the  name  of  hypernephroma  show,  in  some  cases,  a  rapidity  of 
local  spread  and  metastatic  deposit  that  is  not  exceeded  by  any  of  the  other 
forms  of  renal  growth. 


252  INDEX     OF     PROGNOSIS 

2.  The  Duration  of  the  Disease. — Cases  are  recorded  where  symptoms  had 
been  present  for  eight  (Kronlein),  twelve  (Israel),  and  fifteen  (Loumeau)  years 
before  operation  was  performed.  The  average  duration  of  the  illness  from 
the  commencement  of  the  symptoms  to  the  fatal  issue  is,  however,  much  less 
than  this.  It  was  three  and  a  quarter  years  in  32  cases  collected  by  Garceau, 
and  two  and  a  half  years  in  40  cases  collected  by  Richards,  while  Keen,  Pfahler, 
and  Ellis  found  an  average  of  two  and  three  quarter  years.  The  duration  of 
the  disease  is  shortened  by  the  appearance  of  metastases.  When  extensive 
metastases  are  present  in  vital  organs,  such  as  the  lungs  or  liver,  the  patient 
will  only  survive  a  few  months. 

3.  Results  of  Operation. 

a.  Immediate  Results. — The  operative  mortalitj^  including  under  this  head 
deaths  occurring  immediately,  or  any  time  during  the  first  two  months  after 
the  operation,  has  been  much  reduced  during  the  last  decade  ;  but  it  still 
remains  high  compared  ^\•ith  nephrectomy  performed  for  other  diseases. 

Bloch  reports  Israel's  cases  of  nephrectomy  for  malignant  growth.  There 
were  124  cases  with  28  deaths,  an  operative  mortality  of  22-2  per  cent.  Garceau 
collected  143  nephrectomies  for  gro\rth,  with  33  deaths,  a  mortahty  of  23  per 
cent.  The  mortahty,  however,  was  under  this  figure  in  cases  operated  in  the 
last  ten  years.  Shock,  collapse  from  haemorrhage,  and  cardiac  failure  were  the 
causes  of  death.  Braasch  records  a  primary  death-rate  of  11  per  cent  in  the 
Mayo  cUnic. 

b.  Remote  Results. — The  remote  results  of  operation  upon  kidney  growths 
are  to  a  large  extent  dependent  upon  an  early  date  of  operation  and  the 
thoroughness  with  which  the  operation  is  performed.  Certain  conditions  of 
the  growth  facilitate  early  recognition,  or  militate  against  a  timely  diagnosis. 

A  tumour  situated  in  the  lower  pole  of  the  kidne}^  is  in  a  position  favourable 
for  an  early  diagnosis  by  palpation.  Israel  recorded  a  case  where  a  tumour 
in  this  position,  the  size  of  a  nut,  was  diagnosed.  On  the  other  hand,  a  gro^^'th 
situated  in  the  upper  pole  is  concealed  beneath  the  ribs,  and  usually  reaches 
a  considerable  size  before  it  can  be  detected  on  palpation.  The  first  change 
that  can  be  noticed  in  such  cases  is  a  pushing  down  of  the  kidney,  which  is  felt 
lower  than  normal.  The  occurrence  of  haematuria  is  another  factor  in  early  diag- 
nosis. It  is  present  in  90  per  cent  of  adult  cases.  Where  it  is  absent,  diagnosis 
is  not  likely  to  be  made  until  a  later  stage,  when  the  size  of  the  growth  attracts 
attention.  The  form  of  haematuria  is  intermittent,  and  there  may  be  long 
intervals  between  the  attacks.  The  significance  of  this  form  of  haematuria 
is  frequently  not  recognized  bj'  those  in  general  practice  in  this  country,  the 
disappearance  of  the  symptom  being  sometimes  regarded  as  an  indication  of 
cure.  Until  the  practitioner  recognizes  to  the  full  the  importance  of  haematuria 
as  a  symptom,  and  insists  upon  every  case  being  carefully  investigated  by 
•cystoscopy,  catheterization  of  the  ureters,  and,  if  necessary,  by  radiography, 
the  time  for  early  diagnosis  and  favourable  operation  in  a  large  proportion  of 
cases  will  pass  unheeded,  and  the  prognosis,  on  tJiis  account,  will  remain  very 
grave. 

The  operation  performed  for  growths  of  the  kidney  should  aim  at  the  removal 
of  the  perirenal  fat  and  the  lymphatics  included  in  the  perirenal  fascia,  which 
should,  if  possible,  remain  unopened,  and  should  be  traced  to  the  great  vessels. 

A  collection  by  Watson  and  Cunningham  of  143  nephrectomies  for  malignant 
growth  of  the  kidney  showed  the  following  results  :  Death  from  operation, 
33  ;    death  later,  after  operation,  43  ;    survival,  31  ;    not  stated,  36. 

The  43  cases  that  died  later,  after  an  operatiori,  were  distributed  as  follows  : 
one  year  or  under,  22  ;   one  to  two  years,  11  ;   two  to  three  j-ears,  6  ;    three  to 


KIDNEY,     NEW     GROWTHS     OF  253 

four  years,  i  ;  four  to  five  years,  i  ;  seven  to  eight  years,  i  ;  ten  to  eleven 
years,  i.  Death,  these  authors  note,  has  occurred  from  metastases  ten  years 
after  operation,  the  patient  having  enjoyed  perfect  health  in  the  interval. 

The  following  were  the  periods  of  survival  after  operation  in  the  31  cases 
that  remained  well  :  one  year  or  under,  9  ;  one  to  two  years,  6  ;  two  to  three 
years,  7  ;  three  to  four  years,  2  ;  four  to  five  years,  3  ;  five  to  six  years,  2  ; 
six  to  seven  years,  i  ;    nine  to  ten  years,  i. 

Bloch  describes  the  late  results  of  Israel's  cases  of  nephrectomy  for  malignant 
growth  in  124  cases,  of  which  93  survived  the  operation  ;  at  a  two  years'  limit, 
26  remained  well  and  3  died  of  accidental  diseases  ;  thus,  of  all  the  patients 
who  survived  the  operation  32-6  per  cent,  and  of  all  the  operated  cases  27-7 
per  cent,  remained  well.  At  the  end  of  five  years,  19  patients  were  known  to 
be  well.  This  writer  remarks  that  the  permanent  results  of  nephrectomy  for 
renal  growths  are  better  than  those  of  the  operation  for  stomach  and  rectal 
carcinoma,  and  quite  as  good  as  those  for  mammary  carcinoma. 

Braasch  states  that  the  results  in  the  Mayo  clinic  showed  10  per  cent  of  cures 
at  the  end  of  five  years. 

In  20  cases  recorded  by  Rafin,  10  remained  well  for  longer  than  three  years. 

4.  Age. — The  statistics  already  quoted  are  for  new  growths  of  the  kidne)^ 
in  adults.  In  children,  a  number  of  factors  combine  to  make  the  operation 
mortality  higher,  and  render  the  probability  of  recurrence  greater.  Hsematuria 
occurs  in  only  about  16  per  cent  of  cases,  and  is  rarely  present  until  after  an 
abdominal  tumour  is  discovered.  As  a  result,  diagnosis  is  only  made  after 
the  growth  has  assumed  considerable  dimensions.  It  follows  that  the  operation 
is  always  of  a  formidable  character,  while  the  age  of  the  patient  renders  him 
less  able  to  withstand  heroic  surgical  procedures. 

Walker  puts  the  general  mortality  in  children  from  operation  and  recurrence 
at  93-22  per  cent.  Albarran  and  Imbert  give  the  mortality  from  operation 
as  25  to  30  per  cent,  Simon  at  32  per  cent,  and  Lecene  as  low  as  12-44  P^^  cent. 
Recurrence  in  patients  surviving  the  operation  takes  place,  according  to 
Albarran  and  Imbert,  in  81  per  cent  of  cases,  and  Simon  states  the  percentage 
of  recurrences  at  67.  Recurrence  usually  takes  place  rapidly,  and  appears 
within  the  first  year.  Occasionally,  however,  it  may  be  delayed,  and  cases 
where  the  growth  reappeared  three,  four,  and  even  five  years  after  operation 
are  on  record. 

Simon  has  collected  11  cases  in  good  health  a  year  or  more  after  operation, 
among  which  the  longest  were — Israel  five  years,  Doderlein  four  years,  Schmidt 
three  years,  and  Shend  and  Rovsing  each  two  years.  Recently  Bastianelli 
recorded  a  case  well  four  years  after  operation.  The  longest  survival  of  which 
I  have  definite  information  is  a  case  operated  upon  by  Mr.  J.  D.  Malcolm  in 
November,  1S92,  which  was  well  in  February,  191 1,  eighteen  years  and  three 
months  after  operation.  Abbe,  of  New  York,  recorded  two  cases  of  prolonged 
survival ;  in  one  the  patient  died  of  new  growth  of  the  remaining  kidney  four 
and  a  half  years  after  operation  ;  the  other  patient  was  alive  and  well  over 
ten  years  after  operation.  Notwithstanding  such  results,  the  prognosis  in 
children  is  very  grave,  and  some  surgeons  even  advise  against  operation. 

5.  Clinical  Points  in  estimating  Prognosis. — The  important  points  to  take 
into  consideration  are  the  probability  of  spread  beyond  the  capsule,  the  forma- 
tion of  metastases,  the  general  condition  of  the  patient,  and  the  condition  of 
the  second  kidney. 

Spread  beyond  the  capsule  is  indicated  when  the  kidney  is  fixed,  or  is  very 
irregular  in  outline.  Free  mobility  is  a  favourable  sign,  but  a  large  renal 
growth  which  is  fixed  to  the  liver  or  diaphragm  shows  a  considerable  range  of 


254 


INDEX     OF     PROGNOSIS 


vertical  mobility  with  respiration.  A  large  growth  may  appear  fixed,  yet  be 
confined  within  the  capsule  of  the  kidney  ;  but  the  detection  of  fixity  in*  a 
small  renal  growth  is  significant  of  perirenal  spread. 

Pain,  constant  or  localized,  or  radiating  along  nerves,  indicates  nerve  pressure 
outside  the  kidney.  Renal  colic  from  clot  obstruction  should  be  carefully 
distinguished  from  this. 

The  appearance  of  varicocele  on  the  side  of  the  growth  is  due  to  the  engorge- 
ment of  the  perirenal  veins,  but  does  not  necessarily  indicate  spread  of  the 
growth  beyond  the  kidney.  It  disappears  after  nephrectomy,  and  should 
not  be  considered  a  contra-indication  to  operation.  Hochenegg  states  that 
if  the  varicocele  does  not  disappear  in  the  genupectoral  position,  it  is  due  to 
compression  of  enlarged  glands,  and  the  growth  is  inoperable. 

Metastases  are  most  commonly  deposited  in  the  lungs,  liver,  lymph  glands, 
and  bones,  and  careful  examination  of  these,  including  radiographic  examina- 
tion, should  be  made. 

Cachexia  rarely  appears  unless  the  growth  is  advanced,  and  has  spread 
beyond  the  kidney.  The  cardiac  muscle  is  frequently  afiected  by  toxins  from 
the  growth,  and  cardiac  failure  immediately,  or  some  time  after  operation,  is 
not  uncommon.  Dilatation  of  the  heart,  with  a  feeble,  irregular,  unequal 
pulse,  is  a  contra-indication  for  operation. 

As  regards  the  second  kidney,  the  urine  should  be  obtained  and  examined. 
A  trace  of  albumin  and  a  few  tube  casts  are  frequently  present,  and  they  dis- 
appear after  nephrectomy  ;  but  if  these  are  signs  of  advanced  nephritis,  and 
of  a  reduced  renal  function,  operation  is  contra-indicated.  Bilateral  growths 
are  rare.     They  occur  especially  in  childhood.  / .  W.  Thomson  Walker. 


KIDNEY,  POLYCYSTIC. — This  condition  is  almost  invariably  bilateral. 
Luzzato  collected  226  cases,  of  which  only  41  were  unilateral  ;  Lejars  found 
only  2  out  of  63  cases  were  unilateral,  and  Ritchie  only  2  out  of  72  post- 
mortems. The  disease  is  invariably  fatal,  but  the  duration  may  extend  over 
many  years.  Josseraud  found  that  the  age  at  death  in  187  cases  was  as 
follows  :— 


Age 

10—20  years 
20—30      ,, 
30—40      ,, 
40-50      „ 


Cases 

2 

13 
26 
69 


50 — 60  years 
60-70      „ 
70-80      ,, 
80-90      „ 


47 
17 
11 


Nephrectomy  has  a  very  high  mortality.  Seiber  found  an  operation  mortality 
of  32-7  per  cent  in  60  cases.  Of  the  41  cases  that  survived  the  operation,  only 
8  were  known  to  be  alive  after  three  years.  The  longest  survivals  were  4  after 
three  years,  i  after  eight  years,  i  after  six  years,  and  2  after  seven  years. 

/.   W.  Thomson  Walker. 

KIDNEY,  TUBERCULOSIS  OF. — Primary  tuberculosis  of  the  kidney  is  said 
to  be  present  when  the  kidney  is  the  part  of  the  urinary  system  first  affected. 
It  is  obvious,  however,  that,  unlike  the  lung  or  bowel,  the  kidney  cannot  be 
directly  infected  by  the  tubercle  bacillus  from  without,  but  must  always  receive 
the  infection  secondarily  from  some  tuberculous  focus  elsewhere  in  the  body. 
The  nature  and  activit}'^  of  this  extrarenal  tuberculous  focus  has  a  considerable 
influence  upon  the  prognosis. 

In  the  majority  of  cases  of  renal  tuberculosis  that  come  before  the  surgeon, 
either  no  other  tuberculous  focus  can  be  found,  or,  it  one  exists,  it  is  quiescent 
or  obsolete.     In  most  cases  no  other  lesion  can  be  discovered  clinically.     Post- 


KIDNEY,     TUBERCULOSIS     OF  255 

mortem  evidence  goes  to  show,  however,  that  in  such  cases  the  primary  focus 
lies  in  a  tuberculous  bronchial  or  mediastinal  lymphatic  gland.  In  other  cases 
there  is  evidence  of  old-standing  but  apparently  long-quiescent  tuberculous 
disease  of  bones,  such  as  Pott's  curvature,  or  old  sinuses  connected  with  bones, 
or  there  are  ankylosed  joints,  or  a  foot  has  been  amputated,  or  a  knee  excised. 
In  such  cases  the  tuberculosis  of  the  kidney  may  be  considered  on  its  own 
merits,  for  the  other  foci  affect  hardly  at  all  the  future  progress  of  the  disease. 

In  a  smaller  number  of  cases  there  is  active  tuberculous  disease  in  some  other 
part  of  the  body.  A  typical  example  of  this  is  active  pulmonary  tuberculosis. 
Here  the  prognosis  is  dominated  by  the  pulmonary  condition.  In  such  cases 
the  outlook  is  very  grave,  and  the  patient  usually  succumbs  in  about  two  years, 
though  occasionally  after  symptoms  of  only  a  few  months'  duration.  Less 
unfavourable  cases  are  those  in  which  the  active  tuberculosis  is  in  a  position 
where  radical  treatment  is  possible,  such  as  the  foot,  the  epididymis,  or  the 
cervical  glands.  When,  however,  there  are  found  a  number  of  foci  of  tubercle 
distributed  over  the  body — as,  for  instance,  where  there  is  renal  tuberculosis, 
bilateral  tuberculous  epididymitis,  tubercle  of  a  joint,  and  possibly  evidence 
of  bygone  tubercle  of  the  lung — the  resistance  is  so  low  that  the  results  of 
operation  are  unfavourable,  while  the  outlook  under  general  treatment  is  very 
grave.  Renal  tuberculosis  with  tuberculous  epididymitis  is  not  uncommon, 
and  is  not  usually  so  serious.  Radical  operation  may  be  successful  in  per- 
manently curing  the  disease. 

In  the  remarks  which  follow,  renal  tuberculosis  is  considered  as  primary 
in  the  kidney,  with  no  active  tuberculous  lesions  elsewhere,  unless  specially 
mentioned. 

1.  Can  Tubercle  of  the  Kidney  Heal  Spontaneously? — A  few  observers  hold 
the  view  that  a  kidney  which  has  been  the  seat  of  tuberculous  disease  may 
heal  spontaneously  ;  but  the  great  majority  of  those  competent  to  judge  believe 
that  when  tuberculous  disease  attacks  a  kidney,  it  is  not  arrested  until  the 
organ  is  totally  destroyed. 

In  support  of  the  view  that  spontaneous  healing  may  occur,  fibrous  scars, 
some  of  which  show  cretaceous  deposit,  have  occasionally  been  observed.  It 
is  not  certain  that  such  scars  are  of  tuberculous  origin,  but  even  should  this 
be  so,  the  few  cases  that  have  been  recorded  suffice  to  show  that  such  an  out- 
come is  rare.  A  portion  of  the  kidney  affected  with  tubercle  may  be  shut  ofE 
from  the  rest  of  the  organ  by  occlusion  of  that  segment  of  the  pelvis,  and 
chnically,  this  corresponds  to  a  disappearance  of  the  pus  and  tubercle  bacilli 
from  the  urine.  After  a  time,  however,  another  part  of  the  kidney  is  infected, 
and  symptoms  reappear.  It  is  not  unusual  to  find,  at  operation,  that  one 
part  of  the  kidney,  corresponding  to  a  division  of  the  pelvis,  is  distended  with 
tuberculous  material,  and  is  isolated  by  occlusion  of  the  outlet,  while  more 
recent  active  tubercle  is  seen  in  the  open  part  of  the  kidney.  Finally,  the 
whole  kidney  may  be  distended  with  fluid  or  with  semi-solid  tuberculous 
material,  and  the  ureter  be  thick  and  occluded,  so  that  the  entire  organ  is 
destroyed  and  shut  off  (closed  tubercle).  The  tuberculous  disease  here  is 
quiescent  or  obsolete.  It  may  be  stated  that,  short  of  complete  destruction 
of  the  organ,  tuberculous  disease  of  the  kidney  does  not,  with  the  rarest  excep- 
tions, heal  spontaneously. 

2.  Is  Tuberculosis  of  the  Kidney  Unilateral  or  Bilateral  ? — Renal  tuberculosis 
is  unilateral  in  the  earlier,  and  very  frequently  bilateral  in  the  late,  stage.  This 
accounts  for  some  discrepancy  between  the  statistics  of  different  observers. 
Kronlein  states  that  92  per  cent,  Albarran  80  per  cent,  Brongersnia  86  per 
cent,   and  Legueu  85  per  cent  of  cases  are    unilateral,    and   clinical  evidence 


256  INDEX     OF     PROGNOSIS 

obtained  by  catheterization  of  the  ureters,  and  the  results  of  nephrectomy, 
certainly  support  this  view.  Such  statements  must  always  be  subject  to  the 
qualifiGation  that  they  apply  to  the  early  stage.  In  the  late  stage  the  disease, 
in  a  large  proportion  of  the  cases,  is  bilateral.  Post-mortem  statistics  given 
by  Gaultier  show  57  per  cent,  by  Isermeyer  62  per  cent,  and  by  Halle  and  Motz 
33  per  cent  bilateral. 

Whe7ice  does  the  Second  Kidney  derive  its  Infection  P  Do  the  bacteria  come 
from  the  same  focus  as  those  that  infected  the  first  kidney  ?  Direct  evidence 
on  this  point  is  very  difficult  to  obtain,  but  the  results  of  nephrectomy  in 
unilateral  renal  tuberculosis  show  that  the  second  kidney  is  infected,  not  froni 
the  original  primary  focus,  but  from  the  first  kidney.  During  the  first  two 
years  after  nephrectomy  for  tuberculous  kidney,  there  is  a  mortality  of  io-6 
per  cent  from  tuberculosis  of  the  remaining  kidney.  The  tuberculous  disease 
in  the  great  majority  of  these  cases,  if  not  in  all,  was  present  at  the  time  of 
the  nephrectomy.  If  the  mortality  due  to  tuberculosis  of  the  second  kidnev 
after  surviving  two  years  be  examined,  it  is  found  to  be  only  3  per  cent.  If 
this  figure  be  compared  with  the  33  to  62  per  cent  of  infection  of  the  second 
kidney  with  tubercle  where  no  operation  has  been  performed,  the  influence  of 
nephrectomy  upon  the  prevention  of  tubercle  of  the  second  kidney  will  be  realized. 

3.  The  Introduction  of  Sepsis. — Infection  of  a  tuberculous  kidney  with  pyo- 
genic organisms  may  result  from  olood-borne  bacteria,  but  more  frequently  it 
is  an  ascending  infection  up  the  ureter  from  a  bladder  infected  by  catheteriza- 
tion. Pyonephrosis  very  frequently  develops,  and  the  patient  is  dangerously 
ill.  Nephrotomy  obviates  the  urgent  symptoms,  and  should  the  second 
kidney  be  healthy,  nephrectomy  can  be  performed  at  a  later  date  with  a  good 
prospect  of  success.  If  the  bladder  is  infected,  there  is  a  danger  of  ascending 
pyelonephritis  of  the  remaining  kidney. 

4.  Results  of  Medicinal,  Climatic,  and  Tuberculin  Treatment. 

The  administration  of  drugs  has  no  effect  upon  the  progress  of  the  disease, 
but  symptoms  such  as  pain  and  bladder  irritation  can  be  ameliorated. 

A  climate  which  is  warm  and  dry,  with  an  even  temperature,  moderates 
some  of  the  more  distressing  bladder  symptoms  which  accompany  renal 
tuberculosis  ;  but  climatic  treatment  does  not  permanently  influence  the  pro- 
gress of  the  disease. 

Tuberculin  treatment  gives  varying  results.  In  some  cases  of  unilateral  renal 
tuberculosis,  with  or  without  involvement  of  the  bladder,  considerable  benefit 
has  resulted  from  prolonged  administration  of  tuberculin.  After  one  or  two 
years,  tubercle  bacilli  and  all  signs  of  inflammation  have  disappeared  from  the 
urine,  and  there  has  been  no  immediate  recrudescence  of  symptoms.  Informa- 
tion obtained  by  the  cystoscope  and  by  operation  upon  such  cases  shows  that 
the  tuberculous  focus  has  become  isolated  by  occlusion  of  a  part  of  the  renal 
pelvis,  or  of  the  entire  pelvis,  by  closure  of  the  ureter.  The  recrudescence  of 
the  tuberculous  disease  in  other  parts  of  the  kidney  or  urinary  tract  is  to  be 
expected  in  such  cases,  and  it  is  a  mistake  to  suppose  that  the  temporary  dis- 
appearance of  signs  in  the  urine,  and  of  symptoms,  means  a  permanent  cure. 

In  bilateral  renal  tuberculosis,  tuberculin  has  a  more  legitimate  field,  for 
curative  operation  cannot  be  undertaken.  Undoubted  improvement  takes 
place  in  a  good  proportion  of  cases  under  tuberculin  treatment,  but  I  have 
not  seen  any  case  of  cure. 

In  cases  where  there  is  tuberculosis  of  one  kidney  v.^ith  tuberculous  foci 
in  other  parts,  tuberculin  treatment  is  often  of  service,  either  in  combination 
with  nephrectomy,  or  apart  from  operation.  After  nephrectomy,  tuberculin 
treatment  of  genital  tuberculosis  is  likely  to  be  successful. 


KIDNEY,     TUBERCULOSIS     OF 


257 


When  tuberculosis  of  the  kidney  occurs  with  active  tuberculosis  of  the  lungs, 
bones,  and  joints,  tuberculin  treatment  does  not  give  encouraging  results. 
In  some  cases  an  improvement  in  the  renal  disease  takes  place ;  but  the  extra- 
renal foci  are  frequently  unaffected,  or  may  even  appear  to  increase  under  the 
treatment. 

In  estimating  progress  in  the  treatment  of  tuberculosis  of  the  kidney  by 
tuberculin,  attention  should  be  paid  to  the  increase  or  decrease  of  body  weight, 
the  general  feeling  of  vigour,  the  effect  on  pain,  frequency  of  micturition, 
tenderness  and  enlargement  of  the  kidney,  and  haematuria.  Where  vesical 
symptoms  are  present,  the  amelioration  of  these  frequently  provides  a  striking 
demonstration  of  improvement. 

The  specific  gravity  and  pigmentation  of  the  urine  increase  as  the  renal 
condition  improves.  The  quantity  of  pus,  and  the  presence  and  numbers  of 
tubercle  bacilli,  are  critical  tests  of  progress. 

5.  Immediate  Results  of  Operation. — Nephrectomy  in  the  early  stage  of 
renal  tuberculosis  is  the  only  method  by  which  a  cure  can  be  assured,  and  the 
operation  is  indicated  whenever  the  diagnosis  of  unilateral  tuberculosis  is  made. 
A  preliminary  to  modern  operative  treatment  of  renal  tuberculosis  is  the 
examination  of  a  specimen  of  the  urine  of  the  second  kidney,  obtained  by 
catheterization  of  the  ureter.  Nephrectomy,  as  a  curative  operation,  depends 
upon  the  absence  of  the  tubercle  bacillus  and  the  proof  of  a  satisfactory  renal 
function,  as  shown  by  the  examination  of  this  specimen.  If  this  is  not 
carried  out,  the  death-rate  of  nephrectomy  reverts  to  that  of  the  older 
statistics  (25  per  cent),  and  patients  who  would  have  lived  for  some  years 
under  palliative  treatment,  die  from  anuria  after  the  operation. 

Brongersma  collected  515  cases  operated  by  various  surgeons,  with  a 
mortality  of  7-18  per  cent.  He  states  that  when  only  the  statistics  of  surgeons 
who  use  modern  methods  of  diagnosis  as  a  routine  measure  are  taken,  the 
mortality  of  nephrectomy  for  unilateral  renal  tuberculosis  falls  to  2-85  per 
cent. 

A  series  of  statistics  published  in  191 1  shows  the  following  figures  : — 


Israel 
Wildbolz      - 

Asakura 

Andre 

Von  Frisch- 


/1023  (collected) 

\    170  (personal) 

13y 

70 


100 


10  to  15  per  cent 

15 
/        71  per  cent 
I.  (up  to  four  years) 

15  per  cent 


6.  Late  Results  of  Operation. — The  after-history  of  369  patients  on  whom 
nephrectomy  was  performed  for  primary  tuberculosis  shows  that  death  occurred 
after  a  considerable  interval  in  56  (15-2  per  cent).  In  these  cases  the  interval 
varied  from  one  or  two  to  fourteen  or  sixteen  years.  In  329  cases  of 
nephrectomy,  35  (io-6  per  cent)  of  the  patients  died  during  the  first  two  years  ; 
in  these  cases  the  fatal  result  was  due  to  a  spread  of  the  tuberculous  process. 
Of  184  patients  surviving  two  years  after  nephrectomy  for  tuberculosis,  only 
6  (3'2  per  cent)  died  of  tuberculosis  later. 

It  may  be  stated,  therefore,  that  there  is  a  risk  amounting  to  io-6  per  cent 
of  the  patient  dying  of  tuberculosis  during  the  first  two  years,  and  a  risk  of  3-2 
per  cent  of  a  fatal  result  from  tuberculosis  after  this.       /.  w.  Thomson  Walker. 

17 


258  INDEX     OF     PROGNOSIS 

KIDNEY  AND  URETER,  CALCULUS  OF.— In  the  early  stage  of  calculous 
disease  of  the  kidney,  there  is  a  danger  of  a  small  stone  becoming  impacted 
in  the  ureter  and  causing  anuria.  In  the  later  phase,  sepsis  and  uraemia  are 
the  chief  conditions  to  be  feared.  The  following  factors  are  intimately  con- 
cerned vsdth  these  dangers,  and  are  therefore  important  in  estimating  the 
prognosis  :  (i)  The  size  and  number  of  calculi  ;  (2)  Unilateral  and  bilateral 
calculi  ;  (3)  Asepsis  and  infection  ;  (4)  Results  of  operation  ;  (5)  Recurrence 
after  removal :    (6)   Calculous  anuria. 

I.  The  Size  and  Number  of  Calculi. — In  the  earljr  stage,  a  primarj^  calculus 
of  the  kidney  is  single  and  small,  and  the  kidney  is  health}^  or  nearly  so.  Slight 
interstitial  and  parenchymatous  changes,  described  by  Albarran  under  the 
name  of  diathetic  nephritis,  may  be  present,  but  it  is  probable  that  if  the 
calculus  is  removed  thus  early,  no  serious  permanent  damage  to  the  kidney 
will  remain. 

At  this  stage  the  chief  danger  is  impaction  of  the  calculus  in  the  pelvic  outlet, 
or  in  the  ureter,  during  an  attempt  to  expel  it.  When  the  obstruction  is  incom- 
plete or  recurrent,  a  hydronephrosis  results.  When  the  impaction  is  sudden, 
and  obstruction  complete,  there  is  danger  of  anuria  (calculous  anuria)  resulting. 
The  prognosis  in  these  conditions  is  discussed  elsewhere. 

As  the  calculus  increases  in  size,  pressure  upon  the  kidne}^  substance  causes 
interstitial  nephritis  and  atrophy,  until  eventually,  in  the  case  of  a  very  large 
calculus,  the  kidney  substance  is  reduced  to  a  mere  shell.  The  renal  function 
is  now  carried  out  entirely  by  the  second  kidney,  and  if  this  should  fail, 
uraemia  follows. 

At  any  period  in  the  history  of  a  renal  calculus,  but  especially  when  the 
stone  becomes  larger,  or  there  are  a  number  of  calculi  present,  there  is  a  risk 
of  infection  being  superadded.  The  infection  usually  occurs  spontaneously^ 
and  the  path  by  which  it  arrives  is  the  blood-stream  (haematogenous  infection). 
Occasionally  it  follows  septic  catheterization  and  washing  out  the  bladder 
(ascending  infection).  The  influence  of  this  comphcation  on  the  prognosis  will 
be  discussed  later.  Removal  of  a  calculus  in  the  early,  small,  aseptic  stage 
can  be  performed  without  great  destruction  of  renal  tissue,  and  "will  prevent 
this  complication. 

The  use  of  the  x  rays  in  diseases  of  the  urinary  organs  has  been  the  means  of 
greatly  improving  the  prognosis  in  calculus  of  the  Iddney  and  ureter.  In  the 
early  stage,  a  small  stone  will  throw  a  shadow  on  the  ;i;-ray  plate,  and  its  exact 
position  is  demonstrated.  It  is  thus  possible  to  operate  with  certaintj-,  and 
to  extract  the  calculus  with  a  minii  ium  amount  of  destruction  of  kidney  tissue. 
WTien  multiple  calculi  are  present,  '-.heir  number  and  position  are  accurately 
shown  on  the  plate,  and  each  shado  '  is  accounted  for  at  the  operation  by  a 
corresponding  stone.  The  danger  of  overlooking  a  small  calculus  is  thereby 
greatly  reduced.  By  means  of  the  x-ray  plate,  the  operative  measures  required 
can  usually  be  planned  beforehand.  Thoroughness  and  rapidity  of  operating 
are  thus  facilitated.  When  the  calculus  lies  in  the  ureter,  it  frequentl}-  happens 
that  the  symptoms  afford  no  guide  to  the  exact  position  of  the  impacted  stone. 
In  such  a  case  an  exploratorvi-  operation,  which  may  be  of  very  formidable 
character,  is  avoided  by  the  discovery  of  a  shadow  in  the  line  of  the  ureter  on 
the  x-TSLY  plate. 

From  the  foregoing  it  may  be  stated,  that  a  good  prognosis  is  justified  when 
the  calculus  is  single,  aseptic,  and  of  small  size,  although  the  condition  is  not 
■without  some  immediate  risk  of  calculous  anuria.  The  piognosis  is  much  less 
favourable,  and  may  be  very  grave,  when  calculi  are  large,  multiple,  and 
septic. 


KIDNEY     AND     URETER,     CALCULUS     OF  259 

2.  Unilateral  and  Bilateral  Calculi. — -When  one  kidney  contains  a  calculus, 
the  most  frequent  form  of  disease  that  affects  the  second  kidney  is  the  develop- 
ment of  a  calculus  in  this  side  also.  In  the  early  stage  of  calculous  disease, 
bilateral  calculi  are  not  very  common  ;  but  in  the  late  stage,  the  second  kidney 
is  frequently  the  seat  of  calculus. 

Israel  found  bilateral  calculi  in  27  per  cent,  Grau  in  i6-6  per  cent,  Kiister 
in  11-78  per  cent,  and  Morris  in  10  per  cent  of  cases  operated  ;  while  Legueu 
found  calculi  in  both  kidneys  in  50  per  cent  of  76  post-mortem  cases.  The 
latter  may  be  taken  to  represent  the  late  stage  of  the  disease,  while  the  former 
gives  an  indication  of  the  frequency  of  bilateral  calculi  in  the  early  stage.  With 
the  more  general  use  and  the  development  of  radiography,  the  diagnosis  of 
stone  in  the  kidney  is  being  made  at  an  earlier  date,  and  the  number  of  bilateral 
calculi  is  likely  to  be  reduced. 

The  significance  of  bilateral  calculi  depends  upon  the  extent  of  the  disease 
and  the  presence  of  sepsis.  The  development  of  calculi  in  the  second  kidney, 
when  one  organ  is  already  affected,  is  a  grave  complication.  There  are  cases 
where  small  aseptic  calculi  are  formed  in  each  kidney,  and  passed  at  intervals. 
In  such  cases  the  kidneys  appear  to  suffer  little  change,  so  long  as  the  calculi 
pass  freely  along  the  ureters.  The  danger  of  anuria  from  impaction  of  a 
calculus  is,  however,  much  greater,  the  prognosis  after  operation  graver,  and 
the  course  of  the  disease  shorter  than  in  unilateral  calculus. 

When  one  kidney  is  the  seat  of  a  large  calculus  or  of  multiple  calculi  and  the 
second  kidney  contains  a  small  calculus,  when  large  calculi  are  present  in  both 
kidneys,  and  when  bilateral  calculi  are  infected,  the  prognosis  is  very  grave. 
Nephrectomy  in  any  of  these  conditions  is  unwise,  and  a  permanent  cure  after 
removal  of  the  calculi  is  unlikely.  In  very  large  bilateral  calculi  it  is  a  question 
if  the  patient  will  not  live  longer  and  in  greater  comfort  without  operation. 
In  such  cases,  recurrence  of  stone  after  removal  is  frequent,  and  at  each 
operation  there  is  very  considerable  destruction  of  renal  tissue.  The  mortality 
of  nephrolithotomy  in  bilateral  calculus  is  much  higher  than  in  unilateral. 

In  22  collected  cases  of  calculous  disease  where  fatal  anuria  followed  opera- 
tion, there  were  calculi  in  the  second  kidney  in  12,  atrophy  and  degeneration 
in  4,  the  organ  was  the  seat  of  fatty  disease  in  2,  amyloid  disease  in  i,  hydro- 
nephrosis in  2,  and  interstitial  nephritis  in  i. 

In  order  that  the  prognosis  may  be  estimated  in  any  case  of  renal  calculus, 
a  careful  examination  must  be  made  of  the  second  kidney  and  ureter  by  means 
of  the  X  rays  ;  and  the  condition  of  the  urine,  and  the  activity  of  the  renal 
function  of  the  second  organ,  must  be  ascertained  by  examination  of  the  urine, 
and  by  the  use  of  the  tests  of  the  renal  function  after  catheterization  of  the 
ureter. 

Kiister  reports  20  cases  of  operation  on  bilateral  calculi,  in  10  of  which  a 
good  result  followed  ;  fistula  persisted  in  3  cases,  and  there  were  7  deaths  from 
uraemia.  Legueu  had  8  double  operations  ;  of  these,  i  died  of  uraemia,  and 
7  recovered.     Of  the  7  survivors,  2  died  of  uraemia  within  a  year. 

3.  Asepsis  and  Infection. —  At  some  period  in  the  history  of  unoperated 
calculus,  infection  occurs.  In  some  rare  cases,  large  bilateral  calculi  develop 
in  both  kidneys  and  run  their  course  till  the  final  anuria,  with  nothing  more 
than  the  very  niildest  infection  of  the  urine  occurring.  Usually,  however, 
the  urine  is  contaminated  with  B.  coli  communis,  or  with  a  mixed  infection. 
In  some  cases  calculi  develop  in  an  alread}^  infected  kidney.  The  prognosis 
in  infected  calculus  is  much  graver  than  when  the  Iddnej^  remains  aseptic.  The 
mortality  of  operation  is  higher,  the  probabilit}'^  of  recurrence  is  greater,  and 
the  destruction  of  kidney  tissue  is  much  more  rapid. 


26o 


INDEX     OF     PROGNOSIS 


Legueu  quotes  the  following  statistics  in  regard  to  stone  operations  on  aseptic 
and  on  infected  kidneys  : — 

Nephrolithotomy  in  Healthy  or  Slightly  Infected  Kidneys. 


Reporter 

Cases 

Deaths 

Brongersma 

17 

0 

Nicolich 

18 

0 

Zuckerkandl 

8 

2 

Rovsing 

115 

7 

Kapsammer 

21 

2 

Israel 

61 

9 

Kiister 

1()0 

15 

Legueu 

20 

2 

Total 

420 

37 

(or  8'8  per  cent) 

Nephrolithotomy    in    Infected    Kidneys. 


Eeporter 

Cases 

Deaths 

Schmieden  - 

Kiister 

Brongersma 

Nicolich 

Legueu 

211 

251 

2 

4 

5 

43 

50 

2 

3 

1 

Total 

473 

109 

(or  23  per  cent) 

4.  Results  of  Operation. — The  results  of  operation  for  renal  calculus  are 
governed  by  a  number  of  factors,  such  as  the  size  and  number  of  the  stones, 
the  condition  of  the  second  kidney,  the  presence  or  absence  of  sepsis,  the 
operation  performed ;  and,  it  may  be  added,  the  experience  and  skill  of  the 
operator,  for  a  successful  operation  may  demand  a  high  degree  of  both. 

Some  of  these  have  already  been  discussed,  while  others  require  no  elabora- 
tion. It  remains  to  compare  the  results  of  the  different  operations  under 
varying  conditions. 

The  operations  performed  for  renal  calculus  are  {a)  nephrolithotomy,, 
(b)  pyelolithotomy,  and  (c)  nephrectomy. 

a.  Nephrolithotomy. — The  results  of  nephrolithotomy  are  largely  influenced 
by  the  presence  or  absence  of  sepsis  previous  to  the  operation.  Some 
authorities,  notably  Morris,  regard  as  cases  of  nephrolithotomy  only  those  in 
which  the  kidney  is  healthy  and  there  is  no  infection.  Most  surgeons  look  upon 
all  cases  of  removal  of  calculi  from  the  kidney  as  cases  of  nephrolithotomy. 

The  results  in  cases  uncomplicated  by  sepsis  or  dilatation  show  a  very  low 
death-rate.  Watson  collected  135  cases  with  3  deaths  (2-2  per  cent),  and 
Rovsing  115  cases  with  7  deaths  (6-o8  per  cent).  Other  results  have  already 
been  quoted. 

In  infected  cases  the  mortality  is  high,  as  the  results  of  Schmieden  (20-3  per 
cent)  show.  After  nephrolithotomy  the  wound  usually  heals  rapidly,  even 
when  mild  infection  has  been  present.     In  infected  cases  a  fistula  may  persist. 


KIDNEY    AND     URETER,     CALCULUS    OF  261 

and  this  is  occasionally  due  to  calculi  having  been  left  in  the  kidney  pelvis, 
or  to  ureteral  obstruction.  In  Schmieden's  cases  (infected)  a  fistula  followed 
the  operation  in  22-2  per  cent,  while  in  Watson's  collection  (infected  and  non- 
infected)  there  were  fistulas  in  8  per  cent. 

b.  Pyelolithotomy . — This  operation  is  confined  to  a  small  class  of  cases  where 
there  is  a  small  or  moderate-sized  calculus  occupjang  the  renal  pelvis  or  calices, 
or  where  the  pedicle  is  comparatively  long  and  the  loin  not  too  deep.  In 
Schmieden's  statistics  there  are  54  cases  of  pyelolithotomy,  of  which  36  (66-7 
per  cent)  were  completely  healed.  There  were  12  (22-2  per  cent)  recoveries 
with  fistula,  and  6  (ii-i  per  cent)  died. 

In  the  writer's  experience,  the  percentage  of  fistula  following  nephrolithotomy 
and  pyelolithotomy,  given  in  the  statistics  quoted,  is  much  too  high. 

c.  Nephrectomy. — Nephrectomy  for  calculus  is,  compared  with  the  operations 
already  discussed,  a  rare  operation,  and  is  reserved  for  cases  where  uncontrol- 
lable haemorrhage  occurs  during  nephrolithotomy,  where  the  calculi  are  very 
numerous  and  large,  and  where  the  kidney  is  atrophied  or  destroyed  by  dilata- 
tion or  suppuration,  or  where  a  malignant  growth  complicates  the  calculus. 

Secondary  nephrectomy  may  be  called  for  in  urinary  fistula,  recurrence  of 
stone,  or  prolonged  renal  suppuration.  The  conditions  under  which  the  opera- 
tion is  performed  are,  therefore,  of  a  serious  nature,  and  the  outlook  is  very 
grave. 

The  following  statistics  were  collected  by  Watson  :  primary  nephrectomy, 
136  cases,  41  deaths  (30-1  per  cent)  ;  secondary  nephrectomy,  33  cases,  6 
deaths  (i8-i  per  cent). 

5.  Recurrence  after  Removal. — The  recurrence  of  calculi  in  the  kidney  after 
an  operation  for  their  removal  depends  upon  a  number  of  factors.  Incomplete 
removal  of  the  stone  or  stones  at  the  operation  is  a  frequent  cause.  A  deep 
loin  with  a  narrow  space  between  the  rib  and  iliac  crest  ;  a  large,  fleshy  kidney 
with  a  short,  inelastic  pedicle  ;  multiple  calculi ;  an  inefficient  A'-ray  examina- 
tion ;  nervousness  and  inexperience  on  the  part  of  the  operator  :  these  are 
factors  which  have  an  important  bearing  on  the  incomplete  removal  of  stones. 
Occasionally  an  aseptic,  single,  hard  stone  may  be  chipped  in  removal,  and 
the  tiny  fragment  form  the  nucleus  of  a  fresh  concretion.  This  is  much  more 
likely  to  occur  where  the  calculi  are  multiple  and  crumbling. 

Sepsis  is  a  prolific  source  of  recurrence,  phosphatic  stones  being  rapidly 
re-formed  even  after  complete  removal.  The  repeated  formation  of  oxalate- 
of-lime  stones,  and  of  uric-acid  stones,  either  after  expulsion  along  the  ureter 
and  discharge  from  the  bladder,  or  after  operation,  is  the  unfortunate  habit 
of  some  patients,  and  the  underlying  diathetic  condition  is  very  difficult,  and 
sometimes  impossible,   to  control. 

6.  Calculous  Anuria. — Calculous  anuria  results  from  the  impaction  of  a 
small  stone  in  the  ureter  of  one  kidney,  the  second  kidney  being  absent, 
atrophied,  or  diseased  in  varying  degree.  Rarely  the  ureters  of  two  functional 
kidneys  are  simultaneously  blocked  by  calculi.  If  the  anuria  is  untreated  by 
operation,  death  occurs  in  71  per  cent  of  cases  according  to  Legueu,  and  in 
67  per  cent  according  to  Donnadieu.  It  takes  place  usually  about  the  tenth 
or  twelfth  da}-,  after  two  or  three  days  of  uraemia  symptoms.  In  cases  that 
have  recovered,  the  date  of  spontaneous  relief  was  the  third  day  in  i,  the  fifth 
to  the  tenth  in  10,  the  thirteenth  in  i,  the  fourteenth  in  i,  the  fifteenth  in  i, 
and  later  than  the  fifteenth  in  2. 

Operation  should  be  performed  at  the  earliest  possible  moment  in  all  cases 
of  calculous  anuria.  It  has  been  held  that  the  operation  may  be  delayed  until 
the   fifth   or    sixth   day,  as    uraemic   symptoms    rarely   supervene   before   that 


262  INDEX     OF     PROGNOSIS 

time.  This  delay  could  only  be  justified  by  a  large  proportion  of  spontaneous 
recoveries,  and  such  does  not  exist.  Death,  if  it  take  place,  is  a  result,  not  of 
the  operation,  but  of  the  condition  for  which  the  operation  was  performed. 

Huck's  statistics  show  that  the  mortality  rises  each  day  that  operation  is 
delayed.  Before  the  fourth  day  there  is  a  mortalit}^  of  25  per  cent,  before  the 
fifth  day  of  30-7  per  cent,  and  before  the  sixth  day  of  42-1  per  cent.  The 
presence  of  uraemic  symptoms  does  not  contra-indicate  operation  ;  successful 
cases  of  operation  under  these  conditions  have  been  recorded. 

Watson  collected  205  cases  of  calculous  anuria,  and  found  the  following 
results  of  treatment  : — 

Treated  without  operation,  no;    deaths,  80;    mortality,  72-7  per  cent. 

Treated  by  operation,  95  ;    deaths,  44  ;    mortality,  46-3  per  cent. 

These  results  are  capable  of  great  improvement  if  the  necessity  for  early 
and  rapid  operation  is  fully  realized.  /.  w.  Thomson  Walker. 

KNEE  JOINT,  INJURIES  OF  THE.— Year  by  year  we  obtain  a  more  complete 
knowledge  of  the  many  various  consequences  of  an  injury  to  the  knee  joint, 
and  we  are  gradually  becoming  more  accurate  in  our  prognosis  and  treatment. 

Fractures  of  the  patella  and  long  bones  are  considered  elsewhere.  We  have 
here  to  discuss  the  outlook  in  the  following  conditions  :  (i)  Synovitis  and 
hismarthrosis  ;  (2)  Ruptured  ligaments  ;  (3)  Dislocation  of  the  knee  or  of  the 
patella  ;  (4)  Recurrent  disability  [internal  derangement  of  the  knee  joint)  ;  (5)  Per- 
forating wounds. 

I.  Synovitis  and  Haemarthrosis. — The  signs  of  these  conditions  are  well 
known  ;  but  it  is  often  impossible  at  first  to  decide  whether  the  effusion  consti- 
tutes the  whole  trouble,  or  whether  there  is  also  some  injury  to  bone,  ligaments, 
or  cartilages  ;  and  the  prognosis  depends  principally  on  this  very  point.  In  all 
but  the  slightest  cases  a  skiagram  should  be  obtained  to  show  any  bony  lesion, 
such  as  a  fracture  of  the  patella  or  of  the  condyles,  separation  of  the  tibial  spine, 
or  a  foreign  body  composed  of  bone  and  cartilage  dislodged  from  a  condyle. 
Marked  lateral  mobility  with  a  tender  area  over  the  site  of  rupture  points  to 
tearing  of  the  lateral  hgaments.  Rupture  of  the  ligamentum  patellae  is  usually 
obvious,  and  the  patient  is  powerless  to  extend  the  knee.  Antero-posterior 
mobility,  either  in  extreme  flexion  or  extension,  is  a  sign  of  tearing  of  the  crucial 
ligaments. 

When  any  evidence  is  obtained  of  one  or  another  of  these  injuries,  it  is 
necessary  to  expect  a  prolonged  disability  and  perhaps  an  imperfect  final 
result.  Even  when  no  special  signs  are  present  beyond  the  synovitis,  it  is 
impossible  to  promise  a  complete  permanent  recovery,  because  there  may  be 
bruising  or  tearing  of  a  semilunar  cartilage. 

Apart  from  this,  however,  it  is  usual  for  a  simple  synovitis  of  the  knee  to 
be  restored  to  normal  in  a  month  in  mild  cases,  and  in  two  to  three  months 
in  severe  cases,  assuming  that  the  treatment  is  efficient — rest  and  cold  applica- 
tions or  pressure  at  first,  followed  by  massage,  and  when  the  acute  inflammatory 
signs  pass  off,  exercises  and  liniments. 

If  considerable  effusion  comes  on  within  an  hour  of  the  injury,  and  especially 
if  there  is  deep  ecchymosis  of  the  skin  appearing  a  day  or  two  later,  it  is  probable 
that  the  joint  contains  blood,  and  this  is  apt  to  absorb  badly  and  to  leave  a 
permanent  stiffness.     This  result  is  only  too  often  seen  in  a  hasmophihac  knee. 

It  must  be  borne  in  mind  in  giving  a  prognosis  that  in  rare  instances  tubercu- 
losis, osteo- arthritis,  or  acute  epiphysitis  passing  into  acute  necrosis  may  follow 
an  injury ;  but  in  the  first  and  last  of  these,  the  original  mischief  is  seldom  severe 
enough  to  cause  synovitis. 


KNEE    JOINT,     INJURIES    OF     THE  263 

2.  Ruptured    Ligaments. — The  special  signs  of  these  injuries  are  as  follows  : — 
Ruptured  Ligamentnin  Patella;. — A   gap   between   the   patella    and   tubercle 

of  the  tibia,  inability  to  extend  the  knee. 

Ruptured  Lateral  Ligaments. — Excessive  lateral  mobility  ;  tenderness  over 
the  torn  ligament. 

Ruptured  Crucial  Ligaments. — If  complete,  antero-posterior  mobility  in 
extreme  flexion  or  extension.  If  incomplete,  persistent  inability  to  flex  to  a 
right  angle,  even  after  synovitis  has  cleared  up. 

Any  of  these  signs  would  lead  the  surgeon  to  give  a  guarded  prognosis  ; 
recovery  will  take  several  months,  and  there  will  often  be  some  permanent 
disability,  happily  seldom  preventing  the  patient  from  walking.  Several  weeks' 
fixation  will  be  necessary  to  allow  of  sound  healing. 

3.  Dislocations. — Partial  or  complete  dislocation  of  the  knee,  a  rare  accident, 
is  necessarily  accompanied  by  tearing  of  the  important  ligaments  on  which 
the  integrity  of  the  joint  depends,  and  it  is  therefore  bound  to  be  many  months 
before  restoration  to  the  normal  can  take  place.  Usually  there  is  some  per- 
manent weakness  and  limitation  of  movement,  not  sufficient  to  prevent  the 
patient  from  walking. 

Dislocation  of  the  Patella,  especially  the  outward  dislocation,  is  unfortunately 
liable  to  relapse,  especially  in  patients  with  genu  valgum,  and  various  methods 
of  operative  treatment  have  been  devised  for  the  relief  of  this  condition,  but 
none  are  very  satisfactory.  The  disability  is  usually  not  serious,  even  if  the 
patella  is  left  unreduced. 

4.  Internal  Derangement  of  the  Knee. — This  convenient  term  includes  those 
cases  in  which,  nearly  always  as  a  sequel  to  some  acute  or  chronic  injury  in 
the  first  place,  the  joint  repeatedly  gives  way,  locks,  or  suffers  from  recurrent 
attacks  of  pain  and  synovitis  whenever  it  is  wrenched  or  twisted.  Very  similar 
symptoms  may  be  due  to  one  of  four  conditions,  arranged  in  order  of  frequency  : 
[a)  A  torn,  folded,  or  loose  semilunar  cartilage  ;  {b)  A  loose  body  (bone,  cartilage, 
fibrous  tag,  old  clot)  ;  (c)  Nothing  obviously  wrong ;  or  {d)  Hypertrophied 
synovial  fringes  or  alar  ligaments. 

It  is  sometimes  possible  to  make  the  diagnosis  without  opening  the  joint.  A 
very  definite  history  of  locking,  with  a  tender  spot,  and  perhaps  a  depression  over 
the  internal  semilunar  cartilage,  suggest  that  it  is  at  fault ;  loose  bodies  can  often 
be  felt  both  by  patient  and  surgeon,  and  if  bony,  a  skiagram  will  reveal  them. 

The  prognosis  in  internal  derangement  of  the  knee  joint  has  to  be  considered 
under  the  headings  of  non-operative  and  operative. 

It  is  agreed  that  many  cases,  apparently  of  this  disease,  can  be  restored  to 
fair  comfort  without  operation,  by  massage  and  rest  immediately  following 
the  first  occurrence  of  the  trouble.  Sir  William  Bennett  found  it  necessary  to 
operate  on  only  123  out  of  500  patients.  But  it  is  seldom  that  the  knee  can  be 
trusted  for  football  or  other  violent  exercises  ;  also,  if  two  or  three  recurrences 
take  place,  non-operative  treatment  will  scarcely  succeed  in  restoring  the  joint 
to  normal,  though  a  good  form  of  knee-truss  may  prevent  severe  attacks  of 
pain  and  synovitis. 

The  end-results  after  operation  have  been  studied  by  D'Arcy  Power  in  89 
patients  at  St.  Bartholomew's  Hospital.  Of  these  it  was  found  by  correspond- 
ence that : — 

73  had  no  recurrence  of  attacks. 
50  regarded  the  knee  as  good  as  the  other. 
yy  reported  movements  perfect. 
68  had  no  change  in  shape  ;    and 

43  found  the  knee  painless,  whereas  11  had  some  aching  in  wet  weather,  and  35 
always  had  pain. 


264 


INDEX     OF     PROGNOSIS 


Many  were  well  enough  to  play  football  again.  The  writer  has  investigated 
the  after-history  of  40  cases  operated  on  at  the  Bristol  Royal  Infirmary.  In 
aU  of  these,  at  least  six  months  had  elapsed  since  the  operation,  and  in  all  but 
6,  at  least  a  year.  Of  56  operations,  none  died,  and  since  rubber  gloves  were 
introduced,  only  i  case  out  of  47  suppurated,  the  patient  having  taken  off 
his  dressings  and  fiingered  the  wound.     He  finished  with  a  stiff,  swollen  knee. 

End-results  of  Operation  for  Internal  Derangement  of  Knee. 


Lesion 

No-  of  cases 

Excellent 

Good 

Fair 

Bad 

Cartilage  torn  or  very  loose 

Loose  bodies 

Nothing  abnormal,  or  cartilage  (?)  loose 
Synovial  fringes  -         -         -         -         - 
Notes  of  lesion  inadequate  - 

17 
7 
8 
3 
5 

16 

2 
4 

I 

1 
2 

2 
1 
1 

0 

2 
1 
0 

1 

0 

1 
1 
1 

1 

Total 

40         1       2.0 

7        1        4        j        4 

\ 

It  will  be  observed  that  when  there  was  a  definite  lesion  of  the  semilunar  cartilages 
the  results  are  almost  uniformly  excellent.  Six  patients  are  able  to  play  foot- 
ball again,  and  several  are  miners  ;  one  does  his  work  with  comfort  after  having 
parted  with  both  his  internal  semilunar  cartilages.  In  every  case  the  injured 
cartilage  was  removed  ;  stitching  in  place  usually  leads  to  recurrence.  It 
had  been  performed  elsewhere  in  one  of  our  patients,  but  he  had  to  come  to 
have  the  cartilage  excised. 

The  cases  of  loose  body,  though  few  could  be  traced,  are  decidedly  less 
satisfactory.  Apparently  a  loose  body  means  an  osteo -arthritic  joint  in  most 
cases,  which  relapses  after  the  operation,  and  in  one  of  our  series  a  second  loose 
body  was  removed  two  years  afterwards. 

When  nothing  abnormal  is  found,  removal  of  the  internal  semilunar  cartilage 
nevertheless  gave  a  good  result  in  6  out  of  8  of  our  cases.  In  another  patient, 
the  after-history  suggests  that  a  loose  body  was  overlooked. 

We  may  conclude  on  the  whole  that  the  operation  for  internal  derangement, 
provided  asepsis  is  secured,  is  usually  followed  by  the  happiest  results,  except 
in  the  loose-body  cases,  where  the  outlook  is  not  so  certainly  favourable. 

5.  Perforating  Wounds  of  the  Knee. — The  vital  element  in  the  prognosis 
after  this  injury  is,  of  course,  the  occurrence  of  suppuration,  and  its  degree. 
Provided  that  this  can  be  avoided,  the  joint  will  be  restored  to  normal  in  a 
few  weeks.  If  suppuration  take  place,  there  will  probably  be  one  or  two 
months  spent  in  bed,  and  a  permanently  stiff  knee  following,  though  fortunately 
it  is  usually  not  painful. 

In  a  small  proportion  of  the  cases  the  inflammatory  reaction  is  violent,  and 
the  patient  suffers  a  desperate  illness,  with,  it  may  be,  the  formation  of  pyaemic 
abscesses  and  occasionally  a  fatal  result.  This  would  nearly  always  be  averted 
by  early  and  efficient  cleansmg  and  drainage.  In  such  bad  cases, .  the  knee 
may  ankylose  at  right  angles  and  remain  painful  ;  the  writer  recollects  seeing 
one  patient  who,  after  many  operations  and  narrowly  escaping  death  from 
pyaemia,  finally  had  to  suffer  amputation. 

References. — D'Arcy  Power,  Brit.  Med.  Jour.  1911,  i,  61  ;  A.  Rendle  Short,  Bristol 
Med.-Chir.  Jour.  1912,  52. 

A .  Rendle  Short. 

KNEE,  TUBERCULOUS. — {See  Arthritis,  Tuberculous.) 


LARYNX,     CARCINOMA     OF 


265 


LARYNX,  CARCINOMA  OF. — In  this  disease  it  is  necessary  to  divide  cases 
into  the  two  following  classes  : — 

1.  Intrinsic,  i.e.,  those  arising  from  the  vocal  cords  true  and  false,  the  inter- 
arytenoid  region,  the  ventricles  and  the  subglottic  region. 

2.  Extrinsic,  i.e.,  those  springing  from  the  upper  aperture  of  the  larynx  and 
from  the  back  of  the  cricoid  cartilage. 

I.  Intrinsic  Carcinoma  is  not  very  malignant  in  type.  Owing  to  the 
arrangement  of  the  lymphatics  within  the  larynx,  which  do  not  communicate 
with  those  of  surrounding  parts,  but  empty  into  a  pair  of  small  glands  on  either 
side,  glandular  infection  is  uncommon  and  metastases  so  rare  as  to  be  practically 
non-existent. 

Growth  is  often  slow  and,  in  the  absence  of  treatment,  cases  have  been 
recorded  in  which  life  has  been  prolonged  for  ten^  and  thirteen-  years  res- 
pectively. 

Treatment  is  essentially  surgical,  and  consists  in  either  intralaryngular  removal 
through  the  natural  passages,  or  opening  the  larynx  by  thyro-fissure.  The 
former  operation  is  generally  condemned,  and  no  statistics  are  available,  although 
7  cases  of  removal  with  no  recurrence  for  three  years  are  reported  by  Frankel,* 
while  in  5  cases  operated  on  by  Schmiegelow^  recurrence  took  place  in  3. 

Removal  of  intrinsic  laryngeal  carcinoma  by  thyro-fissure  is  probably  now 
the  most  successful  operation  in  the  surgery  of  malignant  disease.  Only  recent 
figures  must  be  considered,  as,  owing  to  improvements  in  technique,  results  have 
become  better  of  late  years. 


Results    of    Thyro-fissure    in    Laryngeal   Carcinoma. 


Died  from  Well  from 

Well  for 

Local 

cases 

operation    1-3  years 

over  3  years 

Recurrence 

Tillev 

5 

1 

1 

3 

0 

Semon" 

25 

1 

4 

14 

3 

Jackson 

14 

0 

7 

4 

3 

StClair  Thomson     - 

10 

0 

4 

4 

Butlin 

21 

1 

— 

— 

— 

Koschier 

5 

i 

4 

— 

— 

Schmiegelow 

20 

4 

9 

— 

— 

Total    - 

100 

8 

29 

25 

8 

Thus,  in  loo  operations,  the  mortality  as  a  result  of  operation  was  8  per  cent. 
Of  79  cases  observed  for  over  i  year,  there  was  no  recurrence  in  54,  or  68  per  cent ; 
while  in  38  cases  observed  for  more  than  3  years,  a  cure  was  established  in  25,  or 
65  per  cent. 

Semon^  has  given  reasons  for  considering  that  if  recurrence  has  not  taken  place 
in  one  year  it  will  not  do  so. 

Thus  the  results  show  an  operative  mortality  of  8  per  cent,  v/ith  cure  in  either 
65  per  cent  or  68  per  cent,  compared  with  figures  for  amputation  of  the  breast  of 
an  operative  mortality  of  5  per  cent  and  a  cure  in  42  per  cent.* 

As  a  result  of  this  operation,  owing  to  the  formation  of  a  cicatricial  band  to 
replace  the  cord  which  has  been  removed,  the  patient  is  as  a  rule  left  with  a  fair 
voice.  Thus  in  20  cases  operated  on  by  Semon,  the  voice  was  good  in  11,  fair  in 
5,  and  only  a  whisper  in  4  cases,  while  Jackson  states  that  in  all  his  cases  the 
voice  was  fair  except  where  recurrence  had  taken  place. 

2.  Extrinsic  Carcinoma  has  a  very  much  more  serious  prognosis.      The  disease 


266 


INDEX     OF     PROGNOSIS 


spreads  to  surrounding  parts,  glandular  infection  occurs  early,  and  life  is 
seldom  prolonged  beyond  three  years  without  operation,  death  usually  taking 
place  from  aspiration  pneumonia. 

Operation  is  the  only  treatment  which  holds  out  any  hope  of  cure ;  a  large 
number  of  cases,  however,  do  not  come  under  observation  until  too  late  a  stage. 

The  operation  consists  of  a  partial  or  complete  laryngectomy,  frequently 
accompanied  by  removal  of  a  portion  of  the  oesophagus  or  pharynx.  The  great 
risk  of  the  operation  is  aspiration  pneumonia,  but  this  risk  has  been  diminished 
recently  owing  to  the  method  of  shutting  off  the  tracheal  opening  from  the 
septic  pharyngeal  discharges. 

In  all  cases,  the  glands  on  either  side  should  be  removed  with  the  larynx,  as 
recurrence  in  glands  is  the  most  frequent  form  met  with  after  operation.  I  have 
placed  together  figures  for  partial  and  complete  removal  of  the  lar^mx,  as  from 
the  point  of  view  of  prognosis  before  operation,  one  frequently  cannot  tell  how 
much  of  the  larynx  it  will  be  necessary  to  remove. 

Partial    or    Complete    Laryngectomy. 


Reporter 

Number  of  Cases 

Koschier    - 

13 

Schmiegelow 

9 

Semon 

5 

Gluck 

84 

J  ackson 

8 

Crile 

24 

Butlin 

7 

Delavan     - 

56 

Death  from. 
operation 


6 
1 

5 
0 
2 
1 
29 


4 
1 
0 

3 


*  Appt'oximate   only. 


Thus,  of  193  cases  operated  on,  the  mortality  as  a  result  of  the  operation  v/as 
44,  or  22" 7  per  cent,  while  as  a  result  of  operation  on  119  cases,  a  cure  was 
obtained  in  28,  or  23-5  per  cent. 

Von  Bruns'  gives,  as  a  result  of  figures  collected  for  complete  laryngec- 
tomy since  1890,  an  operative  mortality  of  19  per  cent,  with  a  freedom  from 
recurrence  of  28  per  cent  in  cases  observed  less  than  one  year  after  operation, 
of  16  per  cent  from  one  to  three  years  after,  and  of  10  per  cent  over  tliree  years 
after. 

Therefore  an  operation  with  a  mortality  of  about  one-fifth  of  the  cases  gives 
a  prospect  of  a  more  or  less  permanent  cure  in  about  a  like  number. 

As  a  result  of  this  operation,  except  in  a  few  cases  in  which  only  a  very  partial 
removal  of  the  larynx  has  been  performed,  the  patient  is  speechless.  A  faint 
whisper  may  be  developed  by  using  the  air  in  the  pharynx,  but  at  the  best  this 
is  only  intelligible  to  those  who  are  in  constant  contact  with  the  individual.  In 
addition,  especially  if  the  pharynx  has  been  much  encroached  on  by  the  opera- 
tion, there  may  be  some  considerable  difficulty  in  swallowing. 

There  is  also,  owing  to  the  impossibility  of  an  effective  cough  without  a  larjmx, 
an  increased  liability  to  bronchial  and  pulmonary  afiections,  and  the  impossi- 
bility of  fixing  the  chest  by  closing  the  glottis  makes  manual  labour  difficult  if 
not  impossible.  All  these  disadvantages  may  cause  a  condition  of  great  mental 
depression. 

In  considering  the  advisability  of  this  mutilating  operation,  however,  it  must 
be  remembered  that  the  condition  of  a  patient  dying  of  a  laryngeal  carcinoma 


LARYNX,     PAPILLOMA     OF  267 

is  a  wretched  one.     Frequently  there  is  great  dyspnoea  and  dysphagia,  and  a 
paUiative  tracheotomy  becomes  necessary. 

References. — ^Gluck,  Jour.  Laryngol.  xviii.  484  ;  -Smith,  Laryngoscope,  1910, 
Feb.  ;  ^Frankel, — V.  Bergmann,  System  of  Surgery,  ii.  241  :  *Arch.  Laryngol.  u.  Rhinol. 
1910  ;  ^Jour.  Laryngol.  1903,  Sept.  473  ;  ®Von  Bergmann,  System  of  Surgery,  ii.  602  ; 
''Handbuch  der  Pract.  Chir.irg.  1907.  ^     j    y^yiaJit. 

LARYNX,  PAPILLOMA  OF. — This  condition  usually  arises  in  infancy  or 
childhood.  In  the  absence  of  treatment  the  growths  may  persist  for  a  prolonged 
period.  As  a  rule,  at  some  time,  frequently  about  puberty,  the  growths  will 
spontaneously  disappear.  This  does  not,  however,  always  take  place,  and  cases 
have  been  recorded  in  which  the  condition  persisted  for  thirty^  and  thirty-live^ 
years.     The  alternative  treatments  are  : — 

1.  Surgical,  [a)  Local  removal  through  the  natural  passages.  (6)  Removal 
by  opening  the  larynx  from  the  exterior,     (c)  Tracheotomy. 

2.  Medical.     The  internal  administration  of  calcined  magnesia  in  large  doses. 

3.  Radium  applications. 

The  great  risk  of  the  condition  is  asphyxia,  and  many  of  the  cases  have  to  be 
tracheotomized  for  acute  dyspnoea  when  first  seen. 

1.  Surgical. — • 

a.  Local  Removal  through  the  Normal  Passages. — This  is  the  treatment  now 
most  comimonly  adopted,  the  operation  being  performed  by  the  direct  method, 
and  frequently  accompanied  by  the  application  of  the  cautery  or  caustics  to 
the  base  of  the  growths.  It  will  relieve  the  symptoms  for  a  time,  but  the 
growths  almost  always  recur  and  the  operation  has  to  be  repeated  many  times 
until  eventually  recurrence  ceases.  A  case  has  been  recorded  in  which  opera- 
tion was  performed  47  times.'     It  is  almost  without  risk  to  life. 

b.  Removal  by  Thyro-fissure. — This  method,  formerly  much  employed,  is 
little  used  now.  It  gives  no  greater  security  against  recurrence  than  the  former 
method,  although  a  greater  risk  to  life  is  incurred.  It  is  too  serious  an  operation 
to  be  lightly  repeated,  although  a  case  is  recorded  in  which  it  was  repeated  17 
times  without  a  cure.* 

c.  Tracheotomy. — In  a  large  number  of  cases  this  has  to  be  performed 
as  a  matter  of  urgency.  It  has  also  been  thought  that  it  will  produce  a  cure  by 
giving  rest  to  the  larynx,  but  it  is  doubtful  if  this  is  so  ;  thus,  cases  have  been 
recorded  in  which  the  growths  persisted  for  fifteen^  and  thirty-five®  years,  in 
spite  of  this  operation. 

2.  Medical. — 

Calcined  Alagnesia. — The  administration  of  this  remedy  in  large  doses  has 
been  recently  tried.  Cures  are  recorded  by  Claone,'  Dortu  and  Masini,  a  total 
of  5  cases,  all  of  which  had  been  under  treatment  by  other  methods.  Rose,"* 
however,  reports  failure  in  2  cases.     The  method  is  therefore  on  its  trial. 

3.  Radium. — This  has  been  tried  on  2  cases  recently  by  Delavan^  and  Abbe,^" 
with  complete  success. 

Harris^i  has  collected  records  of  13  cases  treated  by  him.self  and  others.  In 
all  the  growths  disappeared,  but  recurrence  took  place  in  3. 

Thus  radium,  if  obtainable,  would  seem  to  give  the  best  hope  of  an  immediate 
cure.  Calcined  magnesia  may  cure  in  some  cases,  and  can  do  no  harm.  Tracheo- 
tomy is  often  necessary,  but  will  not  cure  of  itself.  Local  removal  is  almost 
without  risk,  and  can  be  repeated.  It  is  impossible  in  any  given  case  to  say 
when  cure  will  occur. 

References. — ^Packard,  Ann.  of  Otol.  Rhinol.  and  Laryngol.  1910,  Sept.  ;  ^Masini, 
Boll,  delle  Mai.  dclV  Oreichio,  1912,   March,  49  ;    'Tilley,  Jour.  Laryngol.  xxvii,  218  ; 


268 


INDEX     OF     PROGNOSIS 


*Semon,  Proc.  Laryngol.  Soc.  Land.  1894,  Jan.  i,  62  ;  *Blondian,  Presse  Oto-Laryngol. 
Beige,  1910,  July  ;  ®Masini,  ibid.  ;  'Claone,  Ann.  des  Mai.  de  I'Oreille,  etc.  xxxvi,  pt. 
I  ;  SRose,  Jour.  Laryngol.  1913,  June,  318  ;  ^Delavan,  Ann.  of  Otol.  Rhinol.,  etc.  1910, 
Sept.  ;  ^°Ann.  Surg.  1912,  Sept.  470  ;    ^ ^Harris,  Int.  Congress  of  Medicine,  1913. 

A.  J.  Wright. 

LARYNX,  TUBERCULOSIS  OF. — Laryngeal  phthisis  is  for  all  practical 
purposes  only  a  complication  of  pulmonary  tuberculosis,  and  the  prognosis  is 
essentially  that  of  the  lung  condition.  The  laryngeal  disease  usually  occurs 
when  the  pulmonary  condition  is  advanced,  and  the  prognosis  is  always  grave, 
the  mortality  being  probably  about  90  per  cent. 

Although  the  laryngeal  and  lung  conditions  usually  progress  or  improve 
together,  not  infrequently  cases  are  seen  in  which  the  larynx  will  improve  under 
treatment  while  the  lung  gets  worse,  and  the  converse.  The  situation  of  the 
disease  in  the  larynx  is  of  importance,  those  cases  in  which  the  epiglottis  is 
involved  having  the  worst  prognosis,  partly  because  of  the  dysphagia  and 
consequent  difficulty  in  taking  food,  and  partly  because  epiglottic  involvement 
usually  occurs  when  the  lungs  are  extensively  diseased.  Lake  and  BarwelP 
give  the  following  figures  of  the  number  of  deaths  taking  place  while  the  cases 
were  under  observation  : — ■ 


Mortality    in    Laryngeal 

TXTBERCULOSIS. 

Location  of  disease 

Number 
of    cases 

Deaths 

Proportion 

Epiglottis 
Arytenoids 
Vocal  cords  alone 

72 

148 

35 

11 

16 
1 

lin6i 
1  in9| 
1  in  35 

The  results  of  general  treatment  are  those  of  pulmonary  tuberculosis,  except 
that  the  prognosis  is  always  rendered  worse  by  the  presence  of  laryngeal  disease. 
Sanatorium  figures  are  unreliable  in  this  respect,  as  the  majority  of  laryngeal 
cases  have  pulmonary  disease  too  far  advanced  for  sanatorium  treatment.  Cases 
of  healing  of  the  larynx  under  tuberculin  are  given  by  Wilkinson,  Parker, 
and  Blumenfeld,^  and  the  latter  gives  the  number  healed  by  this  treatment  as 
about  5  per  cent. 

The  following  tveaUnents  are  directed  solely  to  the  healing  of  the  laryngeal 
disease  : — 

Silence,  the  use  of  various  pigments  and  caustics,  Pfannenstill's  nascent 
iodine  method,  the  galvano-cautery,  diathermy  and  the  x  rays,  the  removal  of 
disease  with  punch-forceps  and  curettes,  and  major  operations  such  as  tracheo- 
tomy and  laryngectomy. 

For  the  relief  of  the  most  distressing  symptom,  dysphagia,  without  any  idea 
of  cure,  amputation  of  the  epiglottis  and  the  blocking  or  section  of  the  internal 
laryngeal  nerve  have  been  employed. 

Silence,  in  conjunction  with  sanatorium  treatment,  has  met  with  some  success. 
Felix  Semon^  and  Bardswell*  have  recorded  7  and  6  cases  respectively  in 
which  healing  of  the  laryngeal  condition  took  place  under  these  conditions. 

StClair  Thomson^  records  arrest  of  the  laryngeal  disease  in  37  out  of  178  cases 
(20-7  per  cent)  with  sanatorium  treatment  and  voice  rest,  aided  in  15  of  them 
by  local  applications  of  the  galvano-cautery.     These  were  all  selected  cases. 

The  use  of  lactic  acid  and  other  pigments  is  less  employed  than  formerly, 
and  although  isolated  cases  of  healing  have  been  described,  they  are  few,  and  no 
statistics  are  available. 

Pfannenstill's  nascent   iodine  method,"  in  which  the  patient  inspires  ozone 


LARYNX,     TUBERCULOSIS     OF 


269 


while  taking  large  doses  of  iodides,  has  been  employed  on  only  a  limited  number 
of  cases.  The  inventor  has  cured  2  patients  on  whom  he  tried  the  method,  and 
Tidestrom  obtained  healing  in  8  out  of  12  cases ;  but  Stangenberg  only 
found  slight  improvement  in  i  case  out  of  4  treated,  so  that  the  method  is  at 
present  on  its  trial.  The  galvano-cautery'  also  produced  healing  in  a  number 
of  isolated  instances.  A'-rays  and  diathermy  have  only  been  used  in  experimental 
cases.  The  active  local  treatment  by  punches  and  curettes  has  been  largely 
employed.  Heryng,  in  the  treatment  of  252  cases,  obtained  healing  lasting 
for  from  one  to  six  years  in  20  cases,  or  7-8  per  cent;  and  Barwell,  out  of  211 
cases,  obtained  healing  in  20  per  cent,  but  these  cases  were  only  watched  for  a 
short  period  and  were  not  seen  after  leaving  hospital. 

Major  operations  are  seldom  employed,  and  the  results  have  usually  been 
disastrous. 

Gluck  gives  : — 

Major    Operations. 


Operation 

Number 
of  cases 

Healed 

Died 

Tracheotomy         -  * 

Hemilaryngectomy 

Laryngectomy 

7 

2 

20 

1 

2 
4 

9 

6 

13 

Grunwald,  of  64  collected  cases  of  laryngostomy,  found  that  only  8  per  cent 
were  alive  a  short  time  after  operation. 

Amputation  of  the  epiglottis,  in  cases  in  which  it  is  ulcerated  and  the  cause 
of  dysphagia,  will  usually  reheve  this  symptom,  and  is  an  operation  without  risk 
to  life. 

Amputation   of  Epiglottis. 


Halt 

Lockard 

Moeller 


24 

151 

25 


Relief  of 
dysphagia 


per  cent 

100 


100 


The  relief  of  pain  by  the  section  of  the  superior  laryngeal  nerve,  or  by 
injecting  alcohol  into  the  nerve  in  order  to  block  it,  has  been  successfully  and 
largely  used  recently,  and  no  risk  seems  to  accompany  this  method.  The  relief 
of  pain,  in  the  case  of  alcohol  injection,  usually  lasts  about  thirty  days,  and 
the  injection  can  be  repeated. 

Alcohol     Injection    of    Superior    Laryngeal    Nerve. 


Number 
of  cases 

Success  in 

Logan  Turner 

Fetterold 

Helot 

Bertran  and  Castillo 

Grant  -         - 

1 
15 
3 
6 
2 

1 

14 
3 
6 
2 

Total 

27 

2« 

270  INDEX     OF     PROGNOSIS 

Blumenthal  has  recorded  2  successful  cases  of  section  of  the  nerve. 

Thus  larv'ngeal  tuberculosis  is  a  serious  complication  of  a  serious  disease. 
Cases  with  epiglottic  involvement  bear  the  worst  prognosis.  Cases  in  which  the 
lung  condition  remains  stationary,  or  improves,  will  usually  heal  with  silence 
and  sc'natorium  treatment.  Galvano-cautery  and  minor  operative  measures 
may  assist  healing.  Major  operative  measures  are  disastrous.  Eemoval  of 
the  epiglottis  and  blocking  of  the  superior  laryngeal  nerve  give  certain  relief 
of  dysphagia,  without  risk,  in  suitable  cases. 

Referenxes. — ^'■Lake  and  Barwell,  Laryngeal  Phthisis,  1905  ;  ^Zeifs.  f.  Laryngol. 
iv.  4  ;  ^Semon,  Brit.  Med.  Jour.  1906,  ii.  1623  ;  *Bardswell,  Brit.  Med.  Jour.  1907, 
i,  1350  ;  ^StClair  Thomson,  Brit.  Med.  Jour.  1914,  April  11  ;  ^Hygeia,  19 10,  Nos.  5  and 
6  ;    'Siebenmann,    V erhandlungen  des   Vereins  deiitscher  Laryngologen,    1909. 

A.  J.  Wright. 
LATERAL    SINUS    THROMBOSIS.— (5ee  Intracranial    Complications    of 
Ear  Disease). 

LEAD  POISONING. — Metallic  lead  and  practicalh'  aU  its  salts  are  poisonous. 
Even  the  sulphate  and  chromate  are  soluble  in  the  gastric  juice,  and  it  has 
been  found  that  the  addition  of  i  per  cent  peptone  increases  the  solubihty  of 
the  metal  and  of  white  lead.  Probably  the  most  harmful  compound  is  Pb,,0, 
while  there  is  only  one  insoluble  and  therefore  harmless  salt,  viz.,  the  sulphide. 
The  mechanical  as  well  as  the  chemical  composition  of  the  salt  has  some  bearing 
on  prognosis,  for  a  less  soluble  salt  may  be  more  dangerous  than  one  which  is 
more  soluble  but  less  easil}'  powdered.  Individual  susceptibility  is  very  marked  ; 
e.g.,  one  man  in  a  white-lead  factory  began  to  have  symptoms  in  two  weeks, 
and  died  of  acute  plumbism  after  five  and  a  half  months'  work.  In  the  same 
factory  was  a  man  who  had  worked  in  white  lead  for  thirty-two  years,  and 
had  felt  no  ill  effects.  Probably  about  a  quarter  of  all  workers  are  not  suscep- 
tible. There  appears  also  to  be  a  family  susceptibihty ;  hence  the  son  of  a 
lead-poisoned  father  and  mother  should  avoid  all  work  connected  with  lead. 
Females  are  more  susceptible  than  males,  especially  if  they  are  anaemic.  The 
disease  is  liable  to  be  very  much  more  severe,  if  there  is  a  constant  absorption 
of  small  quantities  of  the  poison  over  a  lengthened  period,  than  if  a  large  quantity 
is  taken  on  a  single  occasion.  Further,  when  lead  is  absorbed  into  the  respira- 
tory tract  by  inhalations,  the  onset  of  the  symptoms  is  frequently  earlier,  and 
they  are  of  a  more  severe  character,  than  when  it  is  absorbed  from  the  alimentary 
tract.  In  connection  with  the  length  of  time  of  exposure  necessary  before 
symptoms  arise,  A.  Hamilton,  in  an  analj'sis  of  120  cases,  found  i  case  of 
paralysis  at  the  end  of  one  week's  work,  x  case  of  colic  at  the  end  of  one  week's 
work,  I  case  of  cohc  with  neuritis  after  three  days ;  8  of  the  workers  be- 
came ill  in  less  than  two  weeks,  36  in  less  than  a  month,  and  89  in  less  than 
a  year. 

Recurrences  have  a  worse  prognosis  than  first  attacks.  Lead,  once  absorbed 
into  the  system,  may  remain  latent  for  long  periods,  and  then  make  itself 
felt.  The  symptoms  of  lead  poisoning  may  therefore  develop  for  the  first  time 
after  a  man  has  given  up  all  lead  work  for  some  months,  and  in  certain  cases 
even  a  few  jj-ears  have  inter^'ened  before  the  manifestation  of  the  symptoms. 
One  attack  predisposes  to  another.  It  is  not  possible,  however,  to  assert 
positively  that  a  patient  has  entirely'-  recovered  from  an  acute  attack,  as  insidious 
disease  in  some  of  the  internal  viscera,  such  as  kidneys  or  liver,  may  have  been 
initiated. 

With  reference  to  the  prognosis  of  lead  colic,  the  outlook  is  as  a  rule  very 
good,  provided  there  is  no  gross  organic  disease ;  but  if  the  colic  is  exceedingly 
severe,  the  patient  may  die  during  an  attack. 


LEUCOCYTHMMIA  271 


Cerebral  symptoms  are  dangerous,  especially  if  the  patient  becomes  comatose. 
Epileptiform  fits  may  follow  each  other  in  rapid  succession  and  prove  fatal. 
If  the  patient  gets  over  these  attacks,  recovery  may  be  far  from  complete,  and 
blindness  and  aphasia  may  follow. 

The  mental  condition  may  also  be  permanently  deranged,  or  memory  be 
extremely  defective  ;  lead  may  be  responsible  for  a  condition  closely  resembling 
general  paralysis.  As  a  rule,  however,  the  onset  is  much  more  rapid,  and  the 
prognosis  very  much  better,  for  very  considerable  improvement  may  occur  even 
in  the  third  stage,  the  gait  improving,  paralysis  diminishing,  and  the  intellectual 
faculties  and  speech  becoming  more  clear.  Much  mental  irritation,  however, 
generally  persists  even  in  the  most  favourable  cases.  Haemo-retinitis  may  occur 
with,  or  apart  from,  these  cerebral  symptoms.  About  50  per  cent  of  those  who 
develop  this  eye  trouble  get  permanent  optic  atrophy.  In  the  hsemo-muscular 
form,  the  prognosis  as  to  ultimate  recovery  depends  much  on  the  intensity  and 
duration  of  the  paralysis,  whether  or  not  there  is  persistent  atrophy,  and  on 
the  state  of  the  electrical  reactions.  Paralysis  of  the  deltoid,  biceps,  brachialis 
anticus  and  supinator  longus  occurs  in  the  long-estabhshed  cases,  and  hence 
the  prognosis  is  worse  in  this  form  than  in  the  usual  forearm  type. 

In  very  severe  cases  paralysis  may  extend  to  the  muscles  of  the  larynx, 
the  diaphragm,  and  even  the  intercostals,  and  so  prove  fatal  from  failure  of 
respiration. 

In  plumbic  pseudo-tabes,  recovery  is  sometimes  remarkably  rapid,  even  when 
inco-ordination,  loss  of  muscle  sense,  and  ataxy  have  been  marked. 

The  chronic  cachectic  form  undermines  the  general  resistance  of  the  body, 
rendering  it  more  prone  to  intercurrent  infections.  It  shortens  life  by  inducing 
chronic  disease  of  the  internal  viscera,  more  especially  of  the  kidneys,  arteries, 
and  heart.  It  also  predisposes  to  gout  in  all  its  various  manifestations.  Lastly, 
plumbism  leads  to  abortion,  with  its  own  dangers.  /.  R.  Charles. 

LEISHMANIASIS.— (See  Tropical  Fevers.) 

LEPROSY.- — This  disease  may  become  stationary  in  either  the  anaesthetic 
or  tubercular  form,  and  though  tissues  which  have  been  destroj^ed  are  not 
renewed,  still  the  patient  niay  remain  in  good  health  for  thirty  years  or  more  ; 
it  may  run  a  rapid  course  and  become  generalized,  so  that  the  patient  dies  in 
two  or  three  years  from  leprotic  septicaemia  ;  or  more  frequently  there  is  slow 
progress,  and  death  occurs  from  intercurrent  disease,  of  which  dysentery, 
diarrhoea,  or  pulmonary  complications  are  the  most  common.  The  duration 
of  life  is  shorter  in  the  tubercular  form  (seven  to  eight  years,  as  a  rule)  than  in 
anaesthetic  or  nerve  leprosy  (ten  to  twelve  years).  C.  W.  Daniels. 

LEUCOCYTHffiMIA. — No  question  regarding  leukaemia  can  be  discussed 
without  some  preliminary  understanding  regarding  terminology. 

It  has  been  customary  to  classify  cases  into  the  splenomeduUary  and  lymphatic 
types.  It  is  now  recognized  that  the  enlargement  of  the  spleen  is  a  passive 
process,  and  consequently  the  first  form  is  often  spoken  of  as  medullary  or 
myelogenous.  In  recent  years  there  has  been  a  growing  tendency  to  distinguish 
between  ordinary  large  and  small  lymphocytes,  on  the  one  hand,  and  large  and 
small  myeloblasts  on  the  other.  These  latter  can  be  demonstrated,  by  special 
methods,  to  have  a  more  regular  chromatin  network  and  more  nucleoli  than  the 
lymphocytes,  and  they  are  regarded  as  the  precursors  of  the  granular  mj^elocytes, 
neutrophil,  eosinophil  and  basophil,  which  in  turn  develop  into  polymorpho- 
nuclear leucocytes  with  the  corresponding  type  of  granules. 


272 


INDEX     OF     PROGNOSIS 


It  is  unnecessary  for  our  present  purpose  to  discuss  the  relationship  of  these 
cells,  but  it  is  necessary  to  point  out  that  cases  of  '  myeloblastic  '  leukaemia 
are  not  infrequently  recorded  as  myelogenous.  We  are  not  disposed  to  quarrel 
with  this,  but  if  such  a  description  leads  to  the  beUef  that  these  '  myeloblast ' 
leukaemias  are  to  be  classed  in  the  same  category  as  the  granular  leukaemias 
as  regards  symptoms  or  prognosis,  then  either  the  description  is  unfortunate  or 
the  belief  is  wrong. 

We  may  perhaps  best  get  over  the  difficulty  by  classifying  the  leukaemias  in 
terms  of  the  characters  of  the  preponderating  cells,  as  regards  the  presence  or 
absence  of  granules.  If  the  cells  which  are  unduly  increased  are  non-granular, 
it  is  a  matter  of  little  practical  importance  whether  they  are  to  be  labelled 
lymphoc^'tes  or  myeloblasts. 

We  thus  have  to  deal  with  (i)  Lymphatic  {non-granular)  leukcBmia.  This 
is  usually  acute,  rarely  chronic.  (2)  Medullary  (granular)  leukcBmia.  This  is 
usually  chronic,  very  rarely  acute.      (3)   '  Mixed  '  forms.     (4)   Chloroma. 

I.  Lymphatic  LeukaBmia.- — The  great  majority  of  cases  run  an  acute  course. 
An  early  fatal  result  is  the  usual  outcome,  the  only  exception  being  the  very 
occasional  transition  of  a  case  from  the  acute  to  the  chronic  type  of  the  disease. 
Some  cases  end  fatally  within  forty-eight  hours  of  coming  under  observa- 
tion ;  the  greatest  number  die  between  the  fourteenth  and  thirtieth  day, 
and  an  intermediate  number  live  for  from  three  to  six  months.  Among  the 
symptoms  which  indicate  an  early  termination  are  suddenness  of  onset  and 
high  temperature. 

The  early  onset  of  haemorrhages  is  a  serious  symptom.  Once  a  case  shows 
a  definite  tendency  to  bleeding,  an  early  fatal  termination  is  practically  certain. 
A  single  haemorrhage  from  the  nose  or  other  mucous  membrane  has  not  such 
serious  significance,  but  when  bleeding  from  both  nose  and  gums,  haematemesis, 
or  hematuria  have  appeared,  it  is  likely  to  be  persistent.  Purpura  may  occur, 
and  a  hypodermic  injection  may  lead  to  the  formation  of  a  hasmatoma.  Advanc- 
ing anaemia  is  another  very  grave  omen.  The  anaemia  is  not  merely  due  to  the 
haemorrhages,  but  to  the  unchecked  proliferation  of  lymphocytes  in  the  bone- 
marrow.  The  onset  of  diarrhoea  weakens  the  patient,  but  in  the  absence  of 
more  serious  symptoms  it  is  not  of  much  significance  in  this  form  of  the  disease. 
Attacks  of  pneumonia  or  pleurisy  may  occur,  and  may  determine  an  early  fatal 
issue  in  a  case  which  otherwise  might  have  lasted  a  few  months.  Rupture  of 
the  spleen  is  a  contingency  which  has  occurred. 

Local  necroses,  ulceration,  and  the  formation  of  diphtheritic  membranes  on  the 
gums  or  cheeks,  may  lead  to  a  condition  of  profound  toxaemia.  Haemorrhages 
into  the  eye  or  ear  may  lead  to  blindness  or  deafness. 

Little  significance  can  be  attached  to  changes  in  the  leucocyte  count.  It  is 
certain  that  a  falling  count  is  no  indication  of  improvement.  A  falling  lympho- 
cyte percentage  would  be  a  favourable  omen,  but  we  have  never  known  it  take 
place. 

No  known  form  of  treatment  has  any  beneficial  influence  on  the  course  of  the 
acute  cases.     .X'-ray  application  does  harm. 

In  the  chronic  form,  the  spleen  is  enlarged  and  there  is  also  great  enlargement 
of  the  lymphatic  glands.  Indeed,  the  enlargement,  especially  that  of  the  spleen, 
may  be  taken  as  an  index  of  the  previous  duration  of  the  case. 

The  liver  also  enlarges,  and  lymphomata  may  occur  in  the  skin  and  elsewhere. 

The  counts  in  the  chronic  form  are  much  larger,  as  a  rule,  than  in  the  acute, 
but  the  actual  figures  have  little  relationship  to  the  course  of  the  disease. 

A  fatal  result  is  sooner  or  later  to  be  expected.  Duration  in  most  cases  does 
not  exceed  a  year,  but  chronic  cases  lasting  for  several  years  are  not  unknown. 


LEUCOCYTHMMIA  273 

Advancing  anaemia,  cachexia,  intercurrent  affection,  or  the  onset  of  haemorrhages 
and  acute  symptoms,  may  bring  about  the  end.  On  the  other  hand,  a  few  cases 
undergo  remission  and  may  have  a  precarious  existence  for  a  few  years.  In  the 
remissions  the  leucocyte  count  falls,  but,  as  a  rule,  the  lymphocyte  percentage 
remains  unduly  high.  We  have,  however,  notes  of  one  case,  a  miner,  aged 
sixty-nine,  in  whose  case  a  remission  appeared  to  be  complete. 

The  application  of  x  rays  in  chronic  lymphatic  leukaemia  occasionally  does 
good,  and  has  not  the  harmful  influence  it  exerts  in  acute  cases.  Arsenic  appears 
to  do  good.  We  have  seen  remissions  follow  the  use  of  naphthalene  tetra- 
chloride. 

2.  Medullary  Leuksemia. — Prognosis  is  absolutely  unfavourable.  In  the 
usual  chronic  form,  it  is  difficult  to  make  any  statement  about  duration  on  account 
of  the  insidious  onset.  Most  cases  are  likely  to  live  for  at  least  six  months 
after  they  first  come  under  observation.  They  probably  all  die  within  five 
years. 

The  course  of  the  disease  is  not  uniformly  downwards,  and  remissions  and 
relapses  are  often  seen.  When  remissions  occur,  the  spleen  usually  diminishes 
in  size  and  the  leucocyte  count  falls,  but  the  blood-picture  generally  retains 
its  pathological  quahtative  features.  In  some  cases,  symptoms  ameliorate 
without  improvement  of  any  kind  in  the  blood  or  in  the  size  of  the  spleen.  The 
subject  of  myelocythaemia  is  liable  to  many  disabilities.  Fatal  haemorrhage 
has  been  known  to  follow  such  contingencies  as  an  abortion  or  the  extraction  of 
a  tooth.  Diarrhcea  may  be  a  troublesome  symptom,  and  may  persist  to  such 
an  extent  as  to  shorten  life.  Pressure  by  enlarged  glands  on  important  organs 
may  give  rise  to  serious  symptoms.  Intercurrent  disease  may  have  a  remarkable 
influence  on  the  blood-picture.  The  leucocyte  count  may  fall  to  normal  as  the 
result  of  an  attack  of  influenza,  and  in  some  cases  the  count  becomes  subnormal. 

Such  complications  do  not  much  influence  the  general  course  of  the  disease. 
The  more  serious  complications  of  a  chronic  disease,  such  as  pneumonia  and 
pleurisy,  are  uncommon  in  myelocythaemia,  possibly  on  account  of  the  large 
number  of  polynuclear  cells  in  the  blood. 

Myelocythaemia  occasionally  runs  a  very  acute  course.  In  these  ca.ses  the 
duration  is  from  fourteen  days  to  eleven  months. 

Effect  of  Treatment. — In  x  rays  we  have  a  powerful  agent  for  combating  the 
symptoms  of  myelocythaemia.  Their  effect  is  not  curative,  but  the  excessive 
output  of  leucocytes  may  be  temporarily  checked,  the  organs  are  probably  freed 
to  some  extent  from  the  packing  of  their  substance  with  white  cells,  and  their 
functions  are  for  the  time  being  improved. 

The  treatment  may  succeed  in  establishing  remissions  on  successive  occasions, 
but  sooner  or  later  its  power  fails.  In  all  cases  the  application  must  be  closely 
checked  by  the  examination,  not  only  of  the  leucocytes,  but  of  the  red  cells  also. 
It  is  possible  to  carry  on  the  process  of  irradiation  to  such  an  extent  as  to 
exhaust  the  marrow.     In  many  cases  toxic  symptoms  follow  the  use  of  x  rays. 

The  administration  of  arsenic  is  another  measure  which  has  a  beneficial  influ- 
ence on  the  disease.  The  patient  who  is  in  a  position  to  submit  to  a  combined 
treatment  by  x  rays  and  arsenic  has  a  better  chance  of  a  moderate  prolonga- 
tion of  life  than  a  patient  not  so  favour?bly  circumstanced;  the  organic  pre- 
parations of  arsenic  offer  no  special  advantages.  Salvarsan  has  no  good 
influence  on  the  course  of  the  disease.  Some  strikingly  good  results  have 
recently  been  recorded  as  the  result  of  treatment  by  benzol  in  capsules.  We 
have  not  shared  such  favourable  experience,  and  consider  that  the  treatment 
by  benzol  has  more  risks,  and  confers  less  benefit,  than  treatment  by  at  rays  and 
arsenic. 

18 


274  INDEX     OF     PROGNOSIS 

3.  Mixed  Forms. — ^Mixed  leukaemia  may  arise  in  two  ways  : — 

a.  In  lymphatic  leukaemia,  a  considerable  number  of  myelocytes  may  make 
their  appearance.  This  is  the  result  of  marrow  disturbance ;  the  lymphocyte 
proliferation  acts  as  a  stimulus  to  the  parts  of  the  marrow  not  yet  affected. 
A  large  number  of  nucleated  red  cells  generally  appear  in  the  blood  at  the  same 
time.  The  advent  of  the  myelocytes  does  not  very  materially  influence  prognosis. 
Any  significance  which  may  be  attached  to  their  presence  is  certainly  not 
favourable. 

b.  In  medullary  leukemia,  the  blood-picture  may  become  mixed  by  the  failure 
of  the  marrow  to  elaborate  the  granulations  in  the  cells  before  they  pass  into  the 
blood.  In  this  way  a  larger  number  of  lymphocytes  (myeloblasts)  than  usual 
are  present  in  the  films.  A  high  percentage  of  non-granular  leucocytes  in  a 
case  of  myelocythaemia  adds  to  the  gravity  of  the  outlook. 

4.  Chloroma. — This  condition  may  be  regarded  as  leucocythasmia  associated 
with  the  formation  of  green-coloured  tumours,  particularly  in  connection  with 
periosteum.  Prognosis  is  quite  hopeless.  In  a  general  way  the  outlook  is  the 
same  as  in  simple  leukaemia  of  corresponding  type,  but  owing  to  the  tumour- 
formation,  the  likelihood  of  pressure-symptoms  arising  is  much  greater.  There 
is  also  a  tendency  to  more  rapid  emaciation. 

In  no  form  of  leuksemia  is  any  good  result  to  be  expected  from  splenectomy. 
The  patients  in  whom  the  operation  has  been  performed  rarely  recover  from  it, 
and  if  they  do,  the  course  of  the  disease  is  not  influenced.  g.  L  Gulland. 

A.  Goodall. 

LICHEN  PLANUS. — It  is  difficult  to  lay  down  any  criteria  on  which  to  base 
a  prognosis  in  this  disease.  Except  in  a  few  cases  of  acute  type  which  develop 
rapidly  and  tend  to  clear  up  in  a  few  weeks,  lichen  planus  is  apt  to  be  progressive, 
and  may  last  for  many  months.  Its  course  may  be  shortened  by  treatment, 
and  the  most  important  point  in  the  successful  management  of  the  severe  cases 
is  absolute  rest,  both  mental  and  bodily.  Chronic  patches  of  the  disease  are  best 
treated  by  the  x  rays,  or  by  radium  applied  on  a  flat  plate.  The  affection  may 
run  a  relapsing  course,  but  when  once  it  has  cleared  up  it  shows  much  less 
tendency  to  recurrence  than  psoriasis.  The  writer  has,  hov/ever,  seen  a  few 
cases  in  which  the  disease  has  recurred  after  intervals  of  from  two  to  four  years. 

/.  H.  Sequeira. 

LIP,  CANCER  OF. — As  is  well  known,  this  is  one  of  the  least  malignant 
varieties  of  epithelioma,  but  there  are  cases  even  of  this  disease  in  which  the 
prognosis  may  be  very  grave  from  the  first. 

Prognosis  apart  from  Operation. — Probably  every  case  would  at  last  prove 
fatal  but  the  rate  of  progress  is  extraordinarily  variable.  Sometimes  death 
follows  within  a  few  months  ;  in  other  cases  the  growth  may  last  for  10  years  or 
more.  Probably  the  average  duration  is  about  two  or  three  years.  Extensive 
foul  ulceration  of  the  lip,  face,  and  jaw  takes  place,  and  the  glands  in  the  neck 
enlarge  extremely  and  may  suppurate.  Death  is  usually  due  to  lung  troubles. 
In  34  autopsies,  Rowntree  found  bronchitis,  pneumonia,  or  gangrene  of  the  lung 
recorded  in  29.  Metastases  in  the  viscera  are  uncommon  ;  Rowntree  mentions 
four  in  the  lung,  three  each  in  the  kidney  and  liver,  and  one  each  in  the  thyroid, 
larynx,  brain,  adrenal,  heart,  pancreas,  and  femur.  The  writer  has  seen  large 
metastases  in  the  ovaries,  more  than  six  years  after  the  original  growth  in  the  lip 
of  a  woman  who  smoked  a  clay  pipe. 

Mortality  of  Operation. — The  operation  death-rate  nowadays  is  very  low, 
even  if  the  glands  are  removed.  None  died  out  of  seventy  cases  operated  on  at 
the  Bristol  Royal  Infirmary.  Old  German  statistics  give  a  mortahty  of  7  per 
cent,  but  they  go  back  to  pre-antiseptic  daj^s. 


LIP,     CANCER     OF 


275 


Results  of  Operation  for  Epithelioma  of  Lips. 


Reporter  or    Hospital 

Operation 

Died  of 
operation 

Cases 
followed 

Time 
followed 

'  Cured' 

Eecurred 
or  Dead 

per  cent 

years 

per  cent 

per  cent 

Worner,  Bruns'  Klinik  (pre  1886)   - 

896 

7 

424 

3 

38 

62 

Fricke,  Konig's  Klinik  (1874-96)    - 

114 

7 

106 

3 

66* 

34 

tBristolRoyalInfirmary(i  890-191 2) 
ia)  Lips  only  removed 
(6)  Palpable   glands;  lips    and 
glands  removed 

70 

0 

29 
11 

2 
2 

69 

27 

31 
73 

(c)  Lips   and  glands  removed  ; 
glands  not  palpable 
Mayo  clinic  : 

(a)  All  cases  ;  glands  cleared  - 

- 

— 

12 
99 

2 

1-2 

83 

84 

17 
16 

(h)  Glands  showed  cancer 

— 

— 

12 

1-2 

50 

50 

Bloodgood  : 

(a)  Glands  not  cleared     - 
(h)  Glands  cleared — 

— 

— 

10 

5 

70 

30 

I.  Microscopically  cancerous 

— 

— 

12 

5 

50 

50 

2.  Not  cancerous 

— 

— 

21 

5 

95 

5 

*  III  17  of  these,  patient  followed  for  less  than  3  years. 
t  In  3  of  these,  patient  followed  for  less  than  2  years. 


t 


The  Prospect  of  Cure. — It  will  be  observed  that  even  the  methods  of  pre- 
antiseptic  surgery  were  able  to  report  about  38  per  cent  cured,  and  at  a  later 
period  the  proportion  rose  to  66  per  cent.  No  doubt  with  modern  methods  even 
better  results  can  be  obtained.  Out  of  52  cases  treated  by  operation  and  followed 
up  afterwards  in  the  Bristol  series,  33  (63  per  cent)  were  well  two  years  after. 
Admittedly,  two  years  is  rather  early  to  judge  of  success;  but  out  of  a  dozen 
in  whom  the  neck  was  cleared  although  no  glands  could  be  felt,  83  per  cent  were 
free  from  recurrence.  When  lip  only  was  removed,  69  per  cent  were  well.  The 
figures  are,  however,  small. 

Beckman  has  reported  the  figures  for  the  Mayo  clinic,  but  unfortunately  some 
of  the  cases  have  only  been  followed  a  year,  though  the  majority  are  over  two 
years.  In  84  per  cent,  out  of  99  cases,  a  '  cure  '  was  obtained  ;  in  all  these  the 
glands  were  removed.  Bloodgood  has  followed  a  series  for  five  years,  and  finds 
that  clearing  the  neck  improves  the  prognosis.  Where  the  glands  were  found 
to  be  cancerous,  6  out  of  12  where  cured  ;   when  not  cancerous,  20  out  of  21. 

It  is  quite  clear  that  when  the  glands  are  already  palpably  enlarged,  the  out- 
look is  very  much  graver.  Only  3  out  of  11  of  our  cases  were  alive  and  well 
two  years  after,  and  in  none  of  these  were  the  enlarged  glands  proved  by  the 
microscope  to  be  cancerous,  although  the  growth  on  the  lip  showed  as  typical 
epithelioma  in  section.  When  the  glands  show  cancer  microscopically,  both 
Beckman's  and  Bloodgood's  figures  show  that  half  the  cases  may  be  cured. 

We  conclude,  then,  that  if  the  neck  glands  are  not  enlarged,  the  prospect  of 
cure  is  probably  about  80  per  cent  if  the  neck  is  cleared  and  a  free  removal  made 
of  the  growth  in  the  lip. 

Recurrences  in  the  lip  are  often  amenable  to  treatment,  and  3  out  of  7 
of  our  Bristol  cases  did  well. 

Even  if  a  cure  is  not  effected,  the  patient  is  relieved  of  what  might  afterwards 
be  a  foul  growth,  unless,  of  course,  it  recurs  in  the  lip. 

Date  and  Place  of  Recurrence. — Of  25  recurrences  in  the  Bristol  series,  13 
affected  the  lip  (often  glands  as  well),  and  12  only  the  glands.  Wider  removal, 
therefore,  is  still  called  for.     In  our  cases,  recurrence  in  the  neck  was  usually 


276  INDEX     OF     PROGNOSIS 

within  six  months,  but,  according  to  Rowntree's  statistics,  the  average  was 
seventeen  months.  This  is  probably  too  long.  The  growth  may  come  back 
again  in  the  hp  after  a  great  lapse  of  time.  According  to  Rowntree's  tables,  the 
average  is  twenty-four  months.  We  had  cases  three,  six,  and  even  twenty-four 
years  after  the  original  operation  ;    Rowntree  records  one  sixteen  years  after. 

In  the  Bristol  Royal  Infirmary  statistics,  death  in  the  failed  cases  took  place 
about  eighteen  months  after  operation.  One  survived  for  three  years  ;  another 
died  in  five  weeks. 

Referemces.— Rowntree,  Middlesex  Hospital  Reports,  1906,  vLt,  iiS  ;  ButUn,  Oper- 
ative Surgery  of  Malignant  Disease,  1900,  p.  103  ;  A.  Rendle  Short,  Brit.  Med.  Jour. 
1910,  ii,  426  (an  amplified  account  is  here  utilized)  ;  Beckman,  Jour.  Okla.  St.  M.  Assoc. 
1913,  vi,  p.  185  ;  Bloodgood,  Surg.  Gyn.  and  Obst.  1914,  April,  p.  404. 

A.  Rendle  Short. 

LIVER  ABSCESS.— (.See  Dysentery.) 

LIVER,  ACUTE  YELLOW  ATROPHY  OF.— Until  recently,  this  disease 
was  regarded  as  necessarily  fatal,  because  the  diagnosis  was  considered  to  be 
established  only  by  death  or  necropsy.  It  is  now  recognized  that  cases  presenting 
the  acute  symptoms,  but  not  terminating  fatally  until  several  months  later, 
show  areas  of  hyperplasia  of  the  liver  cells  which  compensate  for  the  areas  of 
acute  atrophy  and  thus  enable  life  to  be  maintained.  These  cases,  called  sub- 
acute atrophy  from  their  duration,  are  examples  of  partial  recovery  from  the 
disease,  and  as  this  compensatory  hj^erplasia  has  been  seen  in  cases  sur\dving 
for  months  and  years,  the  possibility  of  permanent  recovery  cannot  be  denied  ; 
but  in  the  absence  of  exact  confirmation,  scepticism  as  to  their  nature  may  be 
expressed,  though  a  fatal  issue  would  have  silenced  any  doubts.  I  have  seen 
two  such  cases.  There  is  still  much  critical  reserve  about  the  acceptance  of 
such  conclusions,  for  though  in  1880  Wickham  Legg^  collected  twenty-eight 
reputed  cures,  F.  W.  White^  in  1908  estimated  the  recoveries  at  about  the  same 
figure.  Recently  it  has  been  suggested  that  acute  yellow  atrophy  is  due  to  the 
same  causes  as  those  of  epidemic  infective  jaundice  acting  on  a  liver  weakened 
by  some  temporary  strain  or  inherently  weak  (Cockayne).^ 

Medical  Treatment. — Recovery  has  been  recorded  after  repeated  transfusions 
of  saline  solution  in  a  few  cases,  and  the  treatment  of  acid  intoxication  hy  trans- 
fusion with  sodium  bicarbonate  and  enemas  containing  sugar  should  improve 
the  outlook.  In  one  case  to  which  I  gave  horse  serum  which  has  an  autolytic 
action,  on  the  ground  that  the  hepatic  change  is  due  to  autolysis,  recovery- 
followed  ;  but  it  is  obvious  that  no  real  conclusions  can  be  based  on  an 
isolated  observ'ation. 

Efficient  prophylactic  treatment  in  cases  which  may  possibly  pass  into  acute 
3'ellow  atrophy'-  has  some  bearing  on  the  prognosis.  Thus,  jaundice  in  pregnant 
women  should  contra-indicate  chloroform  anssthesia  in  childbirth,  and  the 
use  of  chloral  and  chloretone,  as  chloroform  causes  autolysis  of  the  liver  cells, 
and  should  call  for  the  prevention  of  acidosis  and  constipation.  The  benign 
jaundice  which  may  occur  in  secondary  sj^hLhs  readily  yields  to  mercury,  and 
this  method  of  treatm.ent  may  therefore  be  regarded  as  a  means  of  preventing 
the  onset  of  the  rare  sequel,  acute  yellow  atrophy.  In  a  certain  number  of 
cases,  of  which  Parkes  Weber*  has  collected  fifty-three,  acute  yellow  atrophy 
supervenes  in  the  course  of  secondary  syphilis,  and  may  thus  be  compared  with 
acute  myelitis  in  similar  circumstances.  It  is  much  commoner  in  women  than 
in  men,  and  may  follow  the  specific  jaundice  occasionally  seen  in  secondary 
syphilis.  The  available  observations  show  that  the  Treponema  pallidum  is  not 
present  in  the  liver  of  syphihtic  acute  atrophy,  and  the  hepatic  change  therefore 


LIVER,     CIRRHOSIS     OF  277 

appears  to  be  due  to  poisons  manufactured  elsewhere  and  conveyed  to  the  liver. 
If  this  is  true,  mercurial  treatm.ent  should  cut  short  the  supply  of  poisons  and 
so  improve  the  prognosis,  but  I  cannot  bring  any  figures  to  substantiate  this. 

Prognosis  in  Individual  Cases. — Although  it  be  admitted  that  the  disease  is 
not  invariably  fatal,  the  outlook  in  any  given  case  is  very  gloom5^  It  is  worst 
in  pregnant  women.  Children,  probably  from  their  greater  power  of  repair, 
show  the  changes  of  subacute  atrophy  more  often  than  adults  do,  and  the 
prognosis  is  therefore  less  grave  in  them. 

Special  Danger  Signals. — Rapid  diminution  of  the  liver  dullness,  evidence  of 
grave  renal  changes  as  shown  by  blood-casts  and  albumin  in  the  urine,  acidosis, 
a  hsemorrhagic  tendency,  the  early  onset  of  severe  nervous  symptoms,  coma, 
and  a  very  high  or  very  low  temperature,  show  that  a  fatal  termination  is  near. 

References. — ^^Wickham  Leg?,  Bile,  Jaundice,  and  Bilious  Diseases,  1880,' p.  676; 
^F.  W.  White,  Boston  Med.  and  Surp.  Jour.  igo8,  clviii,  729  :  ^Cockayne,  Quart.  Jour. 
Med.  Oxford,  1912-13  vi,  i  ;  *F.  P.  Weber,  Proc.  Roy.  Soc.  Med.  1909,  ii  (Path. 
Sec.'),   113.  H.  D.  Rolleston. 

LIVER,  CIRRHOSIS  OF. — Under  this  heading  the  following  forms  of 
cirrhosis  will  be  considered  :  (i)  Portal ;  {2)  Biliary,  {a)  hypertrophic, 
{b)  obstructive  ;    and  (3)   Syphilitic. 

I.  Portal  Cirrhosis. 
(Synonyms:     Multilobular,  'Alcoholic,'  Laennec's    cirrhosis). 

The  subject  wUl  be  treated  in  the  following  order  :  first,  some  general  con- 
siderations on  the  prognosis  of  the  disease,  then  the  prognosis  of  hagmatemesis, 
of  jaundice,  and  of  ascites  and  its  treatment,  then  the  influence  of  treatment 
generally  on  prognosis,  and  lastly,  the  prognosis  in  individual  cases. 

The  hepatic  change  is  often  latent,  for  in  about  half  the  cases  in  which  a 
cirrhotic  liver  is  found  at  necropsy,  death  is  due  to  other  causes.  The  prognosis 
is  thus  much  better  than  in  biliary  cirrhosis.  Taking  into  account  the  greater 
frequency  of  cirrhosis  in  males,  the  disease  is  less  often  latent  in  females,  possibly 
because  alcohoUsm  when  once  established  is  even  more  difficult  to  control  than 
in  males.  In  adults,  a  comparatively  early  age  appears  to  be  favourable  as 
regards  greater  tendency  to  improvement,  provided  alcoholic  excess  be  stopped, 
probably  because  the  nutrition  is  better  preserved  and  compensatory  processes 
are  more  readily  effected.  Thus  the  average  age  of  37  patients  in  which 
temporary  or  prolonged  improvement  occurred  was  thirty-nine  years  (Cheadle),^ 
which  is  about  ten  years  less  than  the  average  age  of  fatal  cases  of  cirrhosis. 
In  children  the  prognosis  is  generally  considered  to  be  very  grave  ;  but  from 
a  study  of  74  cases  of  cirrhosis  due  to  alcohol,  E.  Jones-  concludes  that  "  the 
prognosis  is  better  in  children  than  in  adults  when  the  condition  is  slightly 
marked,  but  worse  when  definite  symptoms  of  hepatic  inadequacy  have  set  in." 

Haeraatemesis  occurs  in  about  one-quarter  of  the  cases,  is  usually  an  early 
symptom,  and  is  directly  fatal  in  only  some  5  per  cent  of  the  cases  dying  from 
the  effects  of  cirrhosis.  In  Preble's^  60  collected  cases  of  fatal  gastro-intestinal 
haemorrhage  in  cirrhosis,  death  followed  a  single  hjemorrhage  in  a  third  of  the 
cases.  As  h^ematemesis  may  induce  the  patient  to  alter  his  habits  of  life  at  a 
comparatively  early  period  of  the  disease,  it  is  possible  that  in  this  way  it  exerts 
a  favourable  influence  on  the  course  of  the  disease.  When,  as  occasionally 
happens,  haematemesis  occurs  late  in  the  disease  and  in  the  presence  of  ascites, 
the  outlook  is  very  gloomy.  The  occurrence  of  general  haemorrhages  is  always 
a  grave  sign. 


278  INDEX     OF     PROGNOSIS 

Jaundice,  which  occurs  at  some  time  or  another  in  rather  more  than  a  third 
of  all  the  cases,  may  be  due  to  several  causes,  and  the  prognosis  varies  accordingly. 
Often  it  is  transient,  and  of  the  form  usually  spoken  of  as  catarrhal,  or  it  may 
be  slight,  without  bilirubin  in  the  urine.  In  these  circumstances  it  does  not 
exert  any  appreciable  influence  on  the  prognosis.  On  the  other  hand,  the  onset 
of  jaundice  in  the  late  stages,  or  when  accompanied  by  fever,  multiple  hasmor- 
rhages,  and  nervous  symptoms,  is  a  very  grave  indication  ;  cases  of  this  character 
may  run  an  acute  course,  and  are  more  often  seen  in  comparatively  young 
subjects  who  have  been  drinking  heavil3^ 

Ascites. — The  onset  of  ascites  always  makes  the  outlook  bad.  It  is  true  that 
ascites  may  be  due  to  factors  associated  with  cirrhosis,  especially  chronic 
peritonitis,  and  that  the  prognosis  is  then  not  nearly  so  grave  as  in  ascites  due 
to  uncomplicated  cirrhosis.  But  when  ascites  first  appears,  it  is  seldom  possible 
to  distinguish  between  these  two  conditions,  though  the  presence  of  oedema 
of  the  feet  before  the  onset  of  ascites  is  in  favour  of  uncomplicated  cirrhosis. 
As  time  goes  on,  a  decision  can  be  arrived  at  on  the  ground  that  frequent  tappings 
are  required  in  ascites  due  to  chronic  peritonitis  complicating  cirrhosis,  whereas 
in  uncomplicated  cirrhosis  this  is  not  the  case.  These  points  are  borne  out 
by  the  following  statistics  of  Ramsbottom* :  in  31  cases  of  uncomplicated 
cirrhosis,  the  interval  between  the  onset  of  ascites  and  death  was  on  an  average 
188  days,  the  average  number  of  tappings  two,  and  the  interval  between  the 
first  tapping  and  death  46  days  ;  whereas  in  12  cases  of  cirrhosis  associated 
with  chronic  peritonitis,  the  interval  between  the  onset  of  ascites  and  death 
was  on  an  average  394-6  days,  the  average  number  of  tappings  6-7,  and 
the  interval  between  the  first  tapping  and  death  288  days.  For  statistical 
purposes,  cases  in  which  the  condition  of  the  liver  and  peritoneum  has  been 
examined  must  be  emploj^ed,  for  in  cases  which  recover  it  is  obvious  that  some 
doubt  as  to  the  underlying  condition  must  remain.  But  recovery  certainly 
occurs  after  one  or  more  tappings  in  patients  who  appear  to  have  cirrhosis  ; 
this  has  also  been  confirmed  in  cases  which  have  proved  fatal  from  other  causes, 
years  after  the  disappearance  of  ascites. 

The  Influence  of  Paracentesis. — Although  the  prolongation  of  life  after  tapping 
first  became  necessary  was  only  46  days  in  31  cases  of  uncomplicated  cirrhosis 
(Ramsbottom),  there  is  no  reason  to  believe  that  tapping  per  se  accelerates  the 
end,  for  with  the  present  aseptic  methods,  the  risk  of  infection  of  the  peritoneum 
is  practically  neghgible  as  compared  with  the  discomfort  and  bad  effects  due 
to  pressure  on  other  organs  exerted  by  an  unreUeved  ascites. 

In  Individual  Cases  of  Ascites. — The  prognosis  is  rendered  gloomy  when 
ascites  is  preceded  by  great  tympanitic  distention,  or  by  oedema  of  the  legs,  as 
these  show  that  there  is  grave  toxaemia  ;  by  the  occurrence  of  fever  synchronously 
with  the  onset  of  ascites,  as  this  may  be  due  to  some  complication,  such  as  tuber- 
culosis of  the  peritoneum  or  other  parts  ;  by  concomitant  haematemesis  or 
melaena  ;  or  by  such  rapid  re-accumulation  after  tapping  as  to  require  its 
repetition  in  two  or  three  days,  as  these  events  may  indicate  thrombosis  of  the 
portal  vein. 

Surgical  Treatment  of  Ascites  of  cirrhosis  has  taken  several  forms,  of  which 
the  production  of  vascular  peritoneal  adhesions,  or  the  Talma-IMorison  operation, 
is  the  best  known.  The  operation  is  contra-indicated  in  an  advanced  stage  of 
the  disease  with  much  toxaemia,  by  considerable  jaundice,  and  by  definite  cardiac 
or  renal  disease.  On  the  basis  of  cases  observed  in  Calcutta,  Rogers*  considers 
that  leucocytosis  renders  any  operation  inadvisable.  The  prognosis  is  influenced 
by  the  stage  at  which  the  operation  is  performed.  But  it  might  be  urged 
that  cases  in  the  earlier  stages  are  those  which  might  recover  if  left  to  nature. 


LIVER,     CIRRHOSIS    OF  279 

From  analysis  of  227  cases,  Sinclair  Whites  estimated  that  37  per  cent  were  cured 
and  13  per  cent  improved,  whereas  Willems^  concluded  that  only  4  per  cent 
out  of  250  cases  were  really  successful. 

Other  operations,  such  as  introducing  the  omentum  into  a  subcutaneous 
pocket  in  the  abdominal  wall  (Narath),  or  establishing  permanent  drainage  of 
the  ascitic  fluid  into  the  subcutaneous  tissues  of  the  abdomen  (Paterson)  or 
thigh  through  the  femoral  ring  (Wynter  and  Handley),  entail  much  less  operative 
shock  and  have  been  successful  in  some  cases.  Possibly  the  mechanism  by 
which  improvement  results  is  on  the  same  lines  as  in  '  autoserotherapy, '  or  the 
injection  of  ascitic  fluid,  after  its  removal,  into  the  abdominal  wall ;  by  injecting 
3  dr.  every  other  day,  Vitry  and  Sezary^  induced  profuse  diuresis  and  cure  of 
the  ascites.  Of  Routte's  operation,  which  consists  in  making  an  anastomosis 
between  the  peritoneal  cavity  and  the  internal  saphenous  vein,  Celso^  in  191 1 
collected  10  cases,  of  which  2  only  were  successful. 

In  Egyptian  splenomegaly,  which,  as  in  Banti's  disease,  becomes  complicated 
by  hepatic  cirrhosis,  splenectomy,  or  removal  of  the  supposed  focus  of  the 
disease,  has  been  employed  as  a  curative  measure  in  the  early  stages  when  there 
is  evidence  of  only  moderate  hepatic  cirrhosis  (Richards  and  Day^").  It  is  not 
advisable  when  ascites  or  jaundice  has  appeared.  This  surgical  procedure, 
therefore,  improves  the  prognosis,  but  the  disease  is  not  the  same  as  ordinary 
cirrhosis.  Splenectomy  in  7  cases  of  cirrhosis  in  France  proved  fatal  in  2 
(JuUien^^),  and  at  present  appears  a  risky  and  heroic  procedure. 

The  Effect  of  Treatment  is  greatly  influenced  by  the  period  of  the  disease  at 
which  it  is  undertaken,  and  thus  depends  on  early  diagnosis.  Haematemesis, 
the  earliest  symptom  of  striking  importance,  may,  under  efficient  treatment, 
temperance,  and  care  in  diet,  be  succeeded  by  years  of  life,  and  the  underljdng 
cirrhosis  may  remain  permanently  latent.  But  the  disease  is  compensated,  not 
cured,  and  the  compensatory  mechanisms  may  fail ;  the  hyperplastic  areas  of 
liver  cells  may  degenerate,  or  the  dilated  oesophageal  veins  may  rupture  and 
give  rise  to  hsematemesis. 

In  Individual  Cases. — An  advanced  state  of  the  disease,  with  emaciation,  is 
obviously  ominous.  Fever  points  either  to  a  rapidly  progressive  change  in  the 
liver  or  to  the  presence  of  some  complication,  such  as  tuberculosis,  and  is  there- 
fore a  bad  prognostic.  The  onset  of  drowsiness  is  a  most  grave  sign,  as  showing 
that  lethal  coma  due  to  hepatic  toxaemia  is  imminent.  The  gravity  of  ascites, 
oedema  of  the  feet,  and  multiple  haemorrhages  has  been  referred  to  already. 

The  size  of  the  liver,  if  taken  alone,  is  not  of  much  value  in  prognosis,  for 
though  an  enlarged  liver  due  to  compensatory  hyperplasia  is  found  in  latent 
cases,  enlargement  also  occurs  in  cases  running  an  acute  course,  and  may  be 
temporary  and  due  to  recent  alcoholic  excess.  The  general  symptoms  must 
also  be  taken  into  account ;  in  the  absence  of  well-marked  gastro-intestinal 
symptoms,  a  large  liver  is  a  favourable  sign,  and  vice  versa.  Since  the  spleen 
is  usually  large  and  palpable  in  progressive  and  acute  cases,  and  comparatively 
small  in  latent  cirrhosis,  the  association  of  a  large  liver  and  spleen  is  less  favour- 
able than  a  large  liver  without  a  palpable  spleen. 

Occasional  glycosuria  after  indulgence  in  alcohol  or  a  large  amount  of  sugar 
has  no  special  bearing  on  the  prognosis.  But  in  the  cirrhosis  of  haemochromatosis, 
in  which  diabetes  may  result,  death  usually  occurs  within  a  year  after  the  onset 
of  glycosuria.  The  presence  of  diacetic  acid  in  the  urine,  which  is  rare  in  ordinary 
cirrhosis,  shows  the  presence  of  acidosis,  and  is  therefore  ominous.  Very  well- 
marked  anaemia  is  a  grave  sign,  and,  from  his  experience  in  Calcutta,  which  has 
not  been  confirmed  for  this  country,  Rogers^  considers  that  a  high  leucocytosis 
is  a  bad  sign. 


28o  INDEX     OF     PROGNOSIS 

2.  Biliary  Cirrhosis. 

a.  HypertropMc  Biliary  or  Hanot's  Cirrhosis  is  always,  or  nearly  always, 
fatal.  It  runs  a  chronic  course  with  exacerbations,  and  may  last  as  long  as 
ten  or  more  years,  but  the  average  duration  is  about  five  years,  and  acute 
cases  terminating  within  two  5-ears  from  the  onset  are  sometimes  seen.  In 
India,  especially  in  Calcutta,  there  is  a  form  of  endemic  cirrhosis  clinically 
somewhat  resembling  the  biliary  cirrhosis  of  Europe,  which  attacks  infants. 
It  is  probably  different  in  origin,  and  is  conceivably  aUied  to  kala-azar. 
It  runs  a  more  rapid  course  than  ordinary  bHiary  cirrhosis,  and  it  is  said  that 
95  per  cent  of  the  cases  in  Calcutta  terminate  fatally  before  the  end  of  the  second 
year  of  hfe  (Ghose^^),  Aji  endemic  form  of  intercellular  cirrhosis  characterized 
by  jaundice,  fever,  ascites,  enlargement  of  the  Hver  but  not  of  the  spleen,  and 
by  a  rapid  course  in  six  to  eight  months,  is  said  to  occur  in  Mexico  City  (Carmono 
y  VaUei^). 

Influence  of  Treatment. — A  quiet  life  in  a  healthy  sunny  place,  with  protection 
from  cold  %\T.nds  and  damp,  wiU  prolong  Life.  Calomel  has  been  stated  to  exert 
a  really  beneficial  influence  on  the  disease  and  to  cause  the  jaundice  to  disappear, 
but  more  evidence  is  necessary'  before  this  can  be  accepted. 

Surgical  Treatment. — Drainage  of  the  gall-bladder  has  been  stated  to  give 
good  results;  out  of  17  cases,  13  were  reheved  (Greenough^'^).  But  some  at 
any  rate  of  these  cases  may  have  been  examples  of  chronic  infection  of  the 
bniary  tract  rather  than  of  Hanot's  cirrhosis. 

In  Individual  Cases. — The  patient's  general  nutrition,  inasmuch  as  it  indicates 
the  progress  of  the  malady,  naturally  influences  the  prognosis  as  regards  prolonga- 
tion of  life.  Clubbing  of  the  fingers  is  only  met  vdth  in  long-standing  cases, 
and  therefore  shows  that  the  course  of  the  disease  has  been  slow.  Wasting 
and  the  recurrence  of  the  febrile  exacerbations  or  crises  at  shortened  inter\'als 
indicate  that  the  disease  is  advancing  rapidly.  The  onset  of  %^-idespread  haemor- 
rhages and  the  appearance  of  ascites  and  oedema  of  the  legs  are  very  grave 
indications,  and  the  occurrence  of  compUcations  such  as  pneumonia  and  peri- 
tonitis are  most  serious.  Erysipelas,  however,  may  not  be  fatal,  pro\dded  the 
urinary  excretion  is  well  maintained. 

b.  Obstructive  Biliary  Cirrhosis. — Fibrosis  of  the  hver  ma}'  be  associated  with 
obstruction  of  the  larger  bile-ducts.  Thus,  in  congenital  obhteration  of  the  bile- 
ducts,  cirrhosis  of  the  hver  is  constant ;  and  in  some  cases  of  chronic  obstruction 
of  the  ducts  by  gall-stones,  there  is  increase  of  fibrous  tissue  in  the  hver.  The 
prognosis  of  such  cirrhosis  is  largely  bound  up  -wdth  that  of  the  associated  con- 
dition, and  cannot  be  considered  independently.  Thus,  in  congenital  obhteration 
of  the  ducts  the  outlook  is  hopeless,  and  death  nearly  always  occurs  before  the 
eighth  month  of  life.  In  gall-stone  obstruction  operation  may,  if  the  hepatic 
fibrosis  has  not  become  excessive,  lead  to  a  cure  ;  but  niuch  enlargement  of  the 
liver  and  the  presence  of  secondary  fibrosis  add  to  the  gra\dty  of  the  outlook  in 
gall-stone  obstruction  and  render  operation  more  anxious  than  in  cases  not  so 
comphcated. 

3.     Syphilitic    Cirrhosis. 

In  acquired  syphilis  it  is  probable  that  an  intercellular  cirrhosis,  resembling 
the  well-known  lesion  in  the  congenital  form,  occurs  ;  but  opportunities  for 
verifying  its  presence  are  very  rare.  It  is  possible  that  it  may  be  a  causal 
factor  in  the  benign  jaundice  of  secondary  syphilis,  and  that  when  excessive  it 
may  lead  to  acute  yellow  atrophy — a  very  rare  event  (see  Liver,  Acute 
Yellow  Atrophy  of).  The  prognosis  of  intercellular  cirrhosis  in  adults, 
assuming  that  it  occurs,   is  very  good   as   regards   the   immediate   future,   for 


LUPUS    ERYTHEMATOSUS 


jaundice  and  acute  yellow  atrophy  very  seldom  follow.  It  is,  however,  reason- 
able to  beUeve  that,  if  untreated,  gummatous  change  would  be  more  likely  to 
supervene. 

Syphilitic  Cicatrices. — The  deformed  and  widely-fissured  or  '  botryoid  '  liver, 
due  to  contraction  of  gummas  and  syphilitic  cicatrices,  is  often  called  '  syphilitic 
cirrhosis,'  and  no  doubt  has  a  superficial  resemblance  to  a  coarsely  lobulated 
portal  cirrhosis.  But  it  would  be  more  accurately  described  as  syphilitic 
'  fibrosis  '  than  '  cirrhosis.'  The  prognosis  of  syphUis  of  the  liver  is  discussed 
elsewhere  (see  also  Ascites),  but  it  is  important  to  remember  that  whereas 
gummas  melt  away  under  efficient  treatment,  cicatrices  are  not  affected. 
Antisyphilitic  measures  are  therefore  disappointing,  and  in  addition  misleading, 
if  failure  to  obtain  a  good  result  be  regarded  as  necessarily  eliminating  the 
existence  of  syphilitic  change  in  the  liver. 

Parasyphilitic  Portal  Cirrhosis. — By  this  is  meant  the  occurrence  of  portal 
cirrhosis  in  a  liver  which,  having  formerly  been  affected  with  intercellular  cirrhosis, 
is  left  mth  its  resistance  so  weakened  that  portal  cirrhosis  is  easily  induced. 
This  probably  explains  some  cases  of  portal  cirrhosis  in  early  life,  and  possibly, 
though  this  is  difficult  to  establish,  some  cases  in  adults.  The  prognosis  is  bad, 
and  is  much  the  same  as  in  ordinary  cirrhosis  in  early  life.  As  the  lesion  is 
parasyphilitic,  and  comparable  to  tabes,  in  that  though  not  syphilitic  it  is 
favoured  by  syphilization  of  the  soil,  no  real  benefit  can  be  anticipated  from 
antisyphilitic  treatment. 

Intercellular  Cirrhosis  of  Congenital  Syphilis. — Prompt  and  efficient  anti- 
syphilitic treatment  has  a  most  important  bearing  on  the  prognosis,  not  only  in 
curing  the  condition  at  the  time,  but  in  preventing  the  occurrence  of  the  delaj^ed 
congenital  lesions  such  as  gummas  and  lardaceous  change. 

In  individual  cases  the  outlook  depends  on  the  general  condition  of  the  patient, 
and  on  the  degree  of  enlargement  of  the  liver  and  spleen,  which  may  be  regarded 
as  an  index  of  the  severity  of  the  infection.  General  haBmorrhages  and  jaundice, 
which  are  often  due  to  secondary  infection,  are  very  grave  signs.  Cases  with 
ascites,  which  is  very  rare  except  with  infants  born  with  the  disease  in  an  advanced 
stage,  are  nearly  always  fatal.  The  earlier  in  life  the  general  manifestations  of 
hereditary  syphilis  appear,  the  graver  the  outlook. 

References. — ^^W.  B.  Cheadle,  Some  Cirrhoses  of  the  Liver,  p.  72,  1900  ;  ^E.  Jones, 
Brit.  Jour.  Child.  Dis.  1907,  iv,  i  ;  ^Preble,  Amer.  Jour.  Med.  Sci.  Philad.  1900,  cxix, 
263  ;  *Ramsbottom,  Med.  Chron.  Manchester,  1906-7,  xlv,  7 ;  °L.  Rogers,  Lancet, 
1912,  xi,  355  ;  ^Sinclair  White,  Brit.  Med.  Jour.  1906,  ii,  1287;  'Willems,  Rev.  de  Chir. 
Paris,  1904,  xxiv,  606  ;  ^Vitry  et  Sezary,  Rev.  de  Med.  Paris,  1913,  xxxiii,  86  ;  ^Celso, 
Morgagni,  Milano,  1911,  R.  iv,  liii,  675;  ^"Richards  and  Day,  Trans.  Soc.  Trap.  Med. 
1912,  v,  33  ;  ^^Jullien,  Arch.  Prov.  de  Chir.  Paris,  1911,  xx,  90  ;  ^^Gbose,  Lancet,  1895,  i, 
321 ;  ^"Carmono  y  Valle,  Gaz.  Hebd.  de  Med.  Paris,  1897,  N.S.,  xi,  873  ;  "Greenough,  Amer. 
Jour.  Med.  Sci.  1902,  cxxiv,  979-  ^.  2).  Rolleston. 

LIVER,  INJURIES  OF.— (See  Abdominal  Injuries.) 
LOCOMOTOR  ATAXY.— (5ee  Tabes  Dorsalis.) 
LUNACY.— (See  IMental  Diseases.) 

LUPUS  ERYTHEMATOSUS.—  There  are  two  types  of  this  disease  :— 
(i)  Acute,  and  (2)  Chronic. 

I.  Acute. — In  this  form  the  lesions  are  erythematous,  with  little  or  no  obvious 
infiltration.  The  eruption  develops  rapidly,  involving  both  flush  areas  of  the 
cheeks,  the  root  of  the  nose,  the  backs  of  the  fingers  and  hands,  sometimes  the 
elbows,  knees,  and  ankles,  and  rarely,  the  trunk.  The  patients  are  nearly  all  young 
girls  or  young  women.     \Vhen  pyrexia  and  general  symptoms  exist,  the  prognosis 


282  INDEX     OF     PROGNOSIS 

is  unfavourable,  and  I  have  seen  several  cases  end  fatally.  The  mortahty  is 
about  15  per  cent.  The  fatal  issue  may  be  due  to  pneumonia,  acute  nephritis, 
or  pulmonary  tuberculosis.  In  some  instances  the  eruption  is  haemorrhagic, 
and  this  factor  is  of  grave  omen.  The  prognosis  depends  mainly  upon  the 
general  symptoms,  and  upon  the  pulmonary  and  renal  condition.  In  many  cases 
the  disease  can  be  controlled,  and  sometimes  cured,  by  large  doses  of  quinine  ; 
but  relapses  are  common. 

2.  Chronic. — In  this  more  common  locahzed  form,  the  lesions  are  of  limited 
area,  slowly  spreading  from  one  or  more  foci  on  the  cheeks,  nose,  ears,  or  scalp, 
or  rarely,  the  trunk.  The  patches  are  infiltrated,  red,  and  more  or  less  scaly 
or  crusted,  with  a  tendency  to  produce  scars  in  their  centre  and  to  spread 
peripherally. 

Beginning  in  adolescence  or  early  adult  hfe,  the  disease  has  many  variations 
in  its  activity,  and  may  last  for  many  years.  Even  when  the  lesions  are  quite 
removed  by  treatment,  or  heal  spontaneously,  it  is  impossible  to  promise  a 
permanent  cure.  The  chronic  scaly  patches  are  removed  temporarily  by 
appUcations  of  carbonic-acid  snow,  by  scarification,  and  by  the  local  apphcation 
of  caustics  such  as  iodine,  but  recurrence  is  the  rule.  These  recurrences  are  more 
common  in  the  winter  months  and  in  the  spring.  Residence  in  a  warm  dry 
climate  prevents  relapses,  but  a  return  to  a  humid  region  is  almost  invariably 
followed  by  a  recrudescence  of  the  eruption.  We  are  in  complete  ignorance  of 
the  cause  of  the  disease,  but  attention  directed  to  the  general  health,  and  the 
administration  of  quinine  and  tonics,  are  of  service.  IMany  cases  gradually 
improve  with  the  lapse  of  time,  but  cases  in  which  the  disease  has  been  present 
for  twenty  or  thirty  years  are  not  uncommon. 

Epithelioma  is  a  rare  complication.  In  two  cases  which  I  have  seen,  it  has 
followed  prolonged  ;ir-ray  treatment.  /.  H.  Sequeira. 

LUPUS  VULGARIS. — The  prognosis  in  a  case  of  lupus  vulgaris  depends  on  : 
(i)  The  presence  or  absence  of  disease  of  the  mucous  membranes  ;  (2)  The  extent 
of  the  cutaneous  affection  ;  (3)  The  character  of  the  lesions,  whether  ulcerated 
or  non-ulcerated  ;  (4)  The  general  condition  of  the  patient,  and  the  conditions  under 
which  he  lives,  as  regards  the  supply  of  proper  nourishment,  the  hygiene  of  the 
home  etc.  ;    and  (5)   The  treatment. 

1.  Involvement  of  the  Mucous  Membranes. — This  occurs  i  1  43  per  cent  of  the 
cases  seen  at  the  London  Hospital,  and  the  presence  of  disease  in  the  nasal  cavit\% 
on  the  palate,  on  the  gums  or  the  lips,  or  in  the  pharynx  or  larynx,  materially 
increases  the  difficulty  of  treatment,  and  necessitates  a  guarded  prognosis.  It 
is  my  experience  also  that  one  is  more  likely  to  get  pulmonary  affection  in 
the  cases  in  v.'hich  the  upper  air-pass? ges  are  involved.  Where,  however,  the 
diseased  areas  in  the  nose  are  within  reach,  and  can  be  thoroughly  destroyed  by 
the  curette,  cautery,  or  caustics,  or  combinations  of  treatment  of  this  kind,  a 
cure  is  frequently  effected  ;  but  if  the  surgeon  is  unable  to  remove  the  disease 
entirely,  relapses  in  situ,  with  secondary  involvement  of  the  skin,  are  the  rule. 
Where  the  cartilages  of  the  septum  and  alse  are  involved,  the  outlook  as  regards 
permanent  cure  is  less  hopeful.  The  use  of  nascent  iodine  (Pfannenstill  method) 
after  operation  is  of  great  assistance  in  preventing  recurrence  in  the  intranasal 
cases. 

In  lupus  of  the  gums,  lips,  and  pharjmx,  the  prognosis  depends  upon  the 
thorough  eradication  of  all  the  foci  by  the  cautery,  or  the  application  of  caustics, 
such  as  iodine  (1-5). 

2.  The  Extent  of  the  Cutaneous  Affection. — The  size  of  the  area  involved 
depends,  of  course,  in  the  main  upon  the  duration  of  the  disease,  and  therefore 


LUPUS     VULGARIS  28^ 


upon  early  diagnosis.  Large  single  areas  require  prolonged  treatment,  but  if 
of  the  dry  type,  the  prognosis  is  not  materially  influenced.  Multiple  lesions 
scattered  about  the  face,  limbs,  and  trunk,  such  as  occur  after  the  acute 
exanthems,  do  not  yield  so  readily  as  the  extensive  single-focus  cases,  but 
many  of  the  foci  may  heal  spontaneously  if  they  are  of  small  size. 

3.  The  Character  of  the  Lesions — Ulcerative  or  Non-ulcerative. — The  dry,  non- 
ulcerative form  responds  most  readily  to  the  Finsen  treatment,  and  the  most 
permanent  results,  with  the  least  deformity,  are  obtained  in  it.  A'-ray  treatment 
IS  extremely  tedious  in  this  variety,  and  cure  can  only  be  effected  at  the  risk  of 
•producing  a  telangiectatic  scar,  which  may  become  epitheliomatous.  The 
ulcerative  form  responds  readily  to  treatment  by  local  antiseptics,  followed 
by  exposures  to  the  x  rays.  Relapses  are,  however,  more  common,  and  there  is 
greater  disfigurement. 

4.  The  General  Health  of  the  Patient  and  the  Conditions  under  which  he  lives 
are  of  great  importance.  The  resistance  of  the  individual  to  the  tuberculous 
process  obviously  depends  to  a  large  extent  upon  his  general  health  and  upon  a 
sufficiency  of  good  food,  fresh  air,  and  proper  hygiene.  Where  these  are  unsatis- 
factory, as  in  the  ill-fed  children  of  our  large  cities,  the  effects  of  efficient  local 
treatment  are  often  nullified. 

5.  The  Treatment. — Complete  excision  of  the  affected  area  with  a  good  margin 
of  skin  around,  and  the  removal  of  a  sufficiency  of  the  subjacent  tissue,  give 
admirable  results ;  grafts  may  be  applied  where  the  area  is  extensive.  Lang, 
of  Vienna,  has  reported  a  remarkable  series  of  results.  In  many  cases  the 
operator  does  not  go  deeply  enough,  and,  on  the  face,  the  fear  of  increasing  the 
deformity  is  an  ever-present  drawback  ;  the  result  is  that  patients  return  with 
deep-seated  nodules  which  can  be  seen  through  the  graft.  These,  I  find,  are 
extremely  difficult  to  destroy,  except  by  puncturing  with  the  cautery.  Where 
the  lupus  occurs  in  regions  in  which  the  character  of  the  scar  is  of  Httle  moment, 
the  method  of  excision  is  to  be  advised,  as  giving  excellent  results  with  the 
minimum  loss  of  time  over  treatment 

The  Finsen  treatment  is  especially  indicated  where  the  lesions  are  of  moderate 
size,  and  on  the  face  or  exposed  parts.  The  permanency  of  the  results  is  now 
assured  by  a  lengthy  experience.  I  have  nearly  100  cases  which  have  been  cured 
by  this  method,  and  which  have  been  free  from  recurrence  for  ten  years.  Of  1039 
completed  cases  treated  in  the  Finsen  light  department  at  the  London  Hospital 
during  thirteen  years  :  544  were  free  from  recurrence  for  from  three  to  thirteen 
years;  186  had  been  well  for  less  than  three  years;  117  patients  require 
occasional  treatment  (the}'  have  never  been  free  from  recurrence  for  a  long 
period,  but  are  able  to  follow  their  employment)  ;  in  161  cases  we  were  only  able 
to  report  improvement  (these  patients  had  usually  had  extensive  disease  before 
treatment  was  begun,  or  there  had  been  severe  affection  of  the  mucous  membranes 
of  the  nose,  nasopharynx,  or  buccal  cavity)  ;  only  31  cases  were  found  to  be 
uninfluenced  by  treatment. 

It  should  be  mentioned  that  these  results  were  not  entirely  due  to  the  light 
treatment,  as  ulcerated  areas  received  preliminary  applications  of  the  x  rays, 
and  the  nasal,  palate,  and  buccal  cases  received  special  treatment,  either  by 
operation  or  the  application  of  strong  antiseptics  and  caustics. 

I  should  like  to  take  this  opportunity  of  protesting  against  the  prolonged 
treatment  of  lupus,  especially  of  the  dry  forms,  by  the  x  ra^'S.  I  have  seen  a 
large  number  of  cases  in  which  several  hundreds  of  applications  of  the  rays  have 
been  made.  The  results  in  some  instances  have  been  satisfactory  as  regards  the 
disappearance  of  the  lupus,  though  the  scar  was  an  ugly  one.  This,  however,  is  of 
sm'all  moment  in  comparison  with  the  grave  complication  of  epithelioma.    Chronic 


284  INDEX     OF     PROGNOSIS 

lupus  is  followed  in  about  2  per  cent  of  the  cases  by  epithelioma,  but  prolonged 
treatment  by  the  x  rays  unquestionably  increases  the  liabihty  to  cancer,  and  I 
regret  to  say  that  I  have  seen  cases  in  which  the  prolonged  radiation  has  without 
doubt  been  the  cause  of  this  grave  complication. 

Treatment  of  lupus  by  tubercuhn  is  unsatisfactory.  In  some  cases  of  the 
ulcerative  type,  and  in  many  cases  of  scrofulodermia,  improvement  follows  the 
careful  exhibition  of  this  remedy  ;  but  care  is  required,  for  there  is  no  doubt  that 
its  uncontrolled  administration  has  been  followed  by  an  aggravation  of  the 
disease,  and  also  by  the  stimulation  of  latent  pulmonary  foci. 

Lupus  is  not  in  itself  a  fatal  disease,  but  in  cases  in  which  the  nose,  pharynx, 
and  larynx  are  affected,  there  is  considerable  risk  of  pulmonary  comphcations  ; 
6  of  my  544  patients  cured  of  lupus  died  from  pulmonary  tuberculosis,  and  7 
others  died  while  under  treatment.  Tuberculous  meningitis  also  developed  in 
2  cases  while  the  patients  were  undergoing  the  Finsen  light  treatment. 

/.  H.  Sequeira. 

LYMPHADENITIS,  TUBERCULOUS.— We  shall  confine  ourselves  in  this 
article  to  tuberculosis  of  the  glands  of  the  neck.  The  problems  which  present 
themselves  are  :  (i)  The  prospects  apart  froin  radical  removal  ;  (2)  The  mortality 
of  operation  ;   and  (3)  The  end-results  of  cases  operated  on. 

I.  Prospects  apart  from  Radical  Removal;  or,  in  other  words,  the  effects 
of  medical  and  general  treatment.  Included  under  this  heading  are  cases  in 
which  the  bursting  of  an  abscess  may  be  hastened  by  incision.  We  have  to  ask 
what  prospect  there  is  of  natural  cure,  and  what  is  the  danger  of  tuberculosis 
arising  elsewhere.  Reliable  statistics  of  a  sufficient  number  of  cases  are  not 
abundant ;  but  we  may  probably  accept  Wohlgemuth's  figures  as  sho-wing  that 
about  24  per  cent  are  permanently  cured.  The  majority  either  advance  and 
retrogress  alternately  ;  or  remain  stationary  for  many  years  (the  glands  often 
becoming  calcareous)  ;  or,  more  commonly,  softening  eventually  takes  place, 
and  an  abscess  bursts  through  the  skin,  often  discharging  for  a  long  time,  and 
leaving  an  ugly  scar.  In  children,  the  majority  of  the  cases  eventually  break 
do\vn  ;  in  adults,  the  glands  have  often  been  present  for  a  long  time  already, 
and  frequently  show  no  tendency  to  change  further. 

Given  the  best  possible  conditions,  fresh  air,  good  food,  etc.,  the  results  would 
no  doubt  be  better.  Sea  air,  especially  that  of  the  Kent  coast,  has  a  great 
reputation  in  this  particular  complaint.  But  even  under  the  best  circumstances 
a  considerable  number  of  the  cases  come,  or  ought  to  come,  to  operation. 

Tuhercidin. — The  value  of  tubercuhn  is  not  yet  definitely  determined  by 
statistics,  but  it  often  appears  to  help.  Jones  has  published  a  study  of  79  cases 
treated  at  St.  Mary's  Hospital  inoculation  departm.ent  :  he  describes  27  as 
cured,  21  as  much  better,  iS  better,  8  not  improved,  and  4  worse  ;  it  is  not  stated 
how  long  they  were  observed.  About  half  had  had  a  previous  operation. 
Patients  under  ten  and  over  twenty  did  well  ;  those  between  ten  and  twentj^ 
did  poorly. 

We  may  conclude,  therefore,  that,  given  the  best  conditions,  about  a  quarter 
are  likely  to  be  cured  apart  from  operation  ;  that  the  majority  can  be  improved 
for  a  time,  or  brought  into  a  comparatively  quiescent  state  ;  but  that  many  of 
these  will  eventually  suppurate ;   and  further,  that  tuberculin  is  probably  helpful. 

Recurrence  Elsewhere. — As  to  the  danger  that  tuberculosis  may  develop  else- 
where, the  figures  obtained  by  Demme  from  the  Children's  Hospital  at  Berne, 
where  cases  could  be  followed  up  for  many  years,  even  as  long  as  twenty,  are 
probably  the  most  reliable  we  have  :  of  692  cases  treated  without  operation, 
145  eventually  developed  phthisis,  or  21  per  cent,  and  57  developed  tuberculosis 
elsewhere,  or  8  per  cent,  a  total  of  29  per  cent. 


LYMPHADENITIS,     TUBERCULOUS  285 

It  does  not  follow,  of  course,  that  this  was  always  due  to  self-infection  from 
the  tuberculous  glands  of  the  neck. 

Prognosis  in  Individual  Cases. — If  the  glands  are  already  softening,  cure  will 
only  result  by  the  long  and  uncertain  process  of  external  discharge.  The 
ability  to  obtain  fresh  air  and  good  food,  and  the  response  to  a  few  months  of  this 
treatment,  are  the  principal  guides  to  prognosis. 

2.  Mortality  of  Operation. — This  must  be  very  small  indeed.  Of  649  cases 
at  the  Mayo  clinic,  none  died  of  the  operation  ;  the  nearest  approach  was  a 
fatahty,  four  weeks  afterwards,  from  generahzed  tuberculosis.  Dowd  had  2 
deaths  in  465  operations.  We  may  take  it,  then,  that,  apart  from  the  irreducible 
minimum  of  surgical  calamities,  such  as  anaesthetic  deaths,  status  lymphaticus, 
etc.,  the  danger  is  practically  nil. 

Nerves  may  be  cut,  but  it  is  very  unusual  for  section  even  of  such  important 
structures  as  the  vagus  or  spinal  accessory  to  give  rise  to  any  permanent  trouble  ; 
nor  does  Ugature  of  the  jugular  vein  appear  to  do  any  harm.  Cutting  the 
thoracic  duct  is  another  harmless  bogey. 

3.  End-results  of  Operation. — It  is  difficult  to  quote  figures  as  to  prospects 
of  permanent  cure,  because  operators  differ  so  much  in  the  thoroughness  of  their 
methods. 

Local  Recurrence. — The  number  of  local  recurrences  is  given  by  different 
collectors  of  statistics  as  follows  :  Wohlgemuth,  30  per  cent ;  Dowd,  25  per 
cent  out  of  100  cases  ;  Judd,  8-6  per  cent  out  of  649  cases  in  the  Mayo  clinic  ; 
Miiller,  I3'4  per  cent  out  of  67  cases. 

Wohlgemuth's  records  are  getting  old  now,  and  are  probably  much  too  high. 
The  true  recurrence  rate,  judging  by  what  is  seen  in  ordinary  hospital  practice, 
is  probably  about  i  in  5  or  6,  and  it  would  be  less  if  a  more  complete  clearance  of 
glands  were  made  in  the  first  place.  Some  writers  attach  great  importance  to 
removing  enlarged  tonsils  and  carious  teeth,  as  a  considerable  help  in  preventing 
recurrence. 

Recurrence  Elsewhere. — Another  inquiry  must  be  made  concerning  the  prospects 
of  subsequent  development  of  tuberculosis  elsewhere  after  removal  of  glands  from 
the  neck.  Von  Xoorden  quotes  149  cases,  followed  from  three  to  sixteen  years 
after  operation,  whereof  28  per  cent  showed  evidence  of  tuberculosis  in  other 
organs.  Bios  watched  160  cases  for  three  to  twelve  years  ;  26  per  cent  developed 
phthisis,  and  14  per  cent  tuberculosis  elsewhere.  Dowd,  on  the  other  hand, 
found  only  i  case  of  tuberculosis  of  the  lung  and  3  of  bone  disease  following  on  100 
operations,  but  his  end-results  are  not  so  late  as  the  others.  Judd,  reporting  on 
649  cases  from  the  Mayo  clinic,  found  that  19  afterwards  died  of  phthisis  and  9 
of  tuberculosis  elsewhere  ;  at  the  time  of  operation,  only  10  were  known  to  be 
consumptive.  MiiUer  found  that  6  out  of  67  cases  eventually  died  of  tuberculosis. 
From  these  figures  we  may  conclude  that  removal  of  the  glands  is  by  no  means 
a  sure  preventive  of  further  tuberculous  mischief.  It  looks,  at  first  sight,  as 
though  operation  were  of  no  value  in  averting  such  mischief,  because  there  is 
very  little  difference  between  the  figures  quoted  for  tuberculosis  developing 
elsewhere  in  the  medical  and  surgical  groups.  In  each  group,  probably  about 
I  case  in  4  will  eventually  show  signs  of  phthisis,  bone  disease,  etc.  ;  but  it  m-ust 
be  remembered,  of  course,  that  the  non-operated  group  mostly  includes  the 
milder  types  of  the  disease,  and  the  operated  group  the  severer  types,  in  which 
a  much  larger  proportion  of  cases  of  dissemination  might  have  been  expected. 

References. — Judd,  Ann.  Surg.  1910,  Hi,  758  ;    Attridge,  Surg.  Gynaecol,  and  Obst. 
1908,  vii,  885  ;  Jones,  Brtt.  Med.  Jour.  IQ09,  ii,  531  ;  Miiller,  Ann.  Surg.  1913,  Iviii,  433. 

A.  Rendle  Short. 


286  INDEX     OF     PROGNOSIS 

LYMPH  ADENOMA. — In  considering  the  prognosis  of  lymphadenoma,  it  is 
important  to  understand  exactly  what  is  meant  by  that  name.  Until  1901-2, 
when  the  histological  work  of  Andrewes,  Reed,  and  others  definitel}'-  established 
the  structural  characters  of  lymphadenoma,  cases  of  lymphatic  glandular  enlarge- 
ment which  did  not  fit  into  any  other  group,  and  would  now  be  spoken  of  as 
lymphocytoma  or  pseudo-leukaemia,  were  often  included  ;  and  at  an  earlier 
period,  confusion  occurred  with  some  forms  of  sarcoma,  of  leuksemia,  and  of 
tuberculosis.  At  the  present  time,  microscopic  examination  of  a  gland  should 
be  regarded  as  essential  to  a  diagnosis  of  lymphadenoma,  and  for  strictly  accurate 
statistics  only  cases,  such  as  Longcope's  collectioni  of  86,  in  which  this  has 
been  done,  can  be  accepted.  Othermse,  cases  of  tuberculous  large-celled  hyper- 
plasia of  lymphatic  glands  might  be  thought  to  be  examples  of  lymphadenoma 
cured  by  operation. 

True  lymphadenoma  appears  to  be  invariably  fatal  sooner  or  later.  The 
duration  of  life  after  the  onset  of  symptoms  varies  considerably  ;  the  rare  acute 
form  may  run  its  course  in  some  weeks  or  a  few  months,  but  usually  the  disease 
proves  fatal  within  three  years  ;  thus,  out  of  49  cases  followed  to  their  termin- 
ation, Longcope  found  that  34,  or  69-4  per  cent,  died  ■\\ithin  two  years,  but  2 
survived  for  seven  years  and  another  for  six  years.  The  question  of  prognosis 
is  therefore  concerned  with  the  duration  of  life  rather  than  with  recovery.  The 
usual  course  of  the  disease  is  that  the  glandular  enlargement  is  at  first  and  for 
a  considerable  time  local,  and  with  periods  of  quiescence  or  remission  is  slowly 
progressive,  and  that  eventually  it  generalizes  more  or  less  rapidly  and  is  then 
accompanied  by  fever.  When  the  local  phase  is  latent  or  possibly  absent,  the 
disease  appears  acute  from  the  start. 

Medical  Treatment. — Arsenic  has  a  marked  effect  in  reducing  the  size  of  the 
glands,  and  may  apparently  bring  about  a  long  intermission  in  the  course  of  the 
disease.  Organic  compounds  of  arsenic  such  as  atoxjd,  orsudan,  and  salvarsan 
have  also  been  employed.  Salvarsan  produces  a  rapid  and  striking  effect,  but 
it  should  not  be  used  in  debilitated  patients  late  in  the  course  of  the  disease. 
Arsenic  does  not  act  equally  well  on  all  cases  of  lymphadenoma  ;  sometimes 
it  fails  to  exert  any  influence  ;  and  although  it  may  be  most  successful  for  a  time, 
it  may  lose  its  effect  and  no  longer  control  the  glandular  enlargement ;  or  in 
a  case  in  which  the  glands  have  become  normal  after  the  use  of  arsenic,  a  recur- 
rence is  quite  uninfluenced  by  arsenic.  In  this  connection  it  is  possible  that  in 
its  progress  the  disease  undergoes  some  alteration  in  character,  such  as  trans- 
formation into  sarcoma  (Yamasaki-,  Karsners),  or  that  some  secondary  infection 
of  the  glands  has  occurred. 

X  rays  prolong  life  but  do  not  destroy  the  unknown  cause  of  the  disease  ; 
this  is  shown  by  the  occurrence  of  relapses.  Soft  glands  containing  much  cellular 
elements,  and  the  spleen,  diminish  in  size,  but  hard  fibrous  glands  are  unchanged. 
According  to  McNalty,*  x  rays  do  not  influence  cases  with  the  relapsing  t}^e  of 
fever.  In  some  cases,  although  diminution  in  size  follows  x-ra.y  treatment,  the 
glandular  enlargement  recurs  very  rapidh^  when  the  exposures  are  discontinued 
(Morton, 5  Reid^).  The  application  of  x  rays  may  induce  a  grave  toxemia  and, 
as  shown  experimentally,  normal  lymphoid  tissue  may  be  extensively  destroyed 
and  grave  damage  be  done.  In  42  collected  cases  Pancoast^  found  that  a 
'  symptomatic  cure  '  occurred  in  18,  improvement  in  14,  and  no  change  or  slight 
improvement  only  in  10.  A  further  report  on  27  of  these  cases  showed  that  17 
had  died  of  the  disease,  3  from  toxaemia  ascribed  to  x-ray  treatment,  and 
that  2  more  would  shortly  succumb  ;  7  were  well  three  or  four  years  after 
the  first  symptomatic  cure,  and  i  a  year  after  ;  but  4  of  these  8  had  had 
relapses.  Thus,  as  a  cure  for  three  or  four  years  was  obtained  in  25  per  cent 
of  the  cases,  the  influence  of  x  rays  on  prognosis  is  extremely  good. 


LYMPH  ADENOMA  287 


Surgical  Treatment  is  only  admissible  in  the  early  stage  when  the  disease 
is  localized  to  a  group  of  superficial  glands,  as  in  the  neck.  From  a  priori 
considerations  it  is  perfectly  logical  to  remove  the  primary  focus  so  as  to  prevent 
generalization  ;  in  some  instances  this  has  been  thought  to  delay  the  course  of 
the  disease.  In  a  case  under  my  care  there  was  an  interval  of  five  years  between 
operation  and  death.  On  the  other  hand,  it  is  often  impossible  to  remove  all 
the  glands  involved  when  the  parts  are  exposed,  and  in  some  instances  recurrence 
and  generalization  occur  rapidly  after  operation  ;  the  later  event,  however,  is 
not  necessarily  due  to  operation,  as  it  may  have  begun  before  the  surgical 
procedure.  It  is  possible  that  ;r-ray  exposures  soon  after  operation  might  be 
beneficial  by  acting  on  the  inoperable  glands.  Although  operation  may  be 
desirable  to  relieve  pressure  symptoms  or  to  prevent  deformity,  its  influence 
from  a  prognostic  point  of  view  is  probably  bad. 

Prognosis  in  Individual  Cases. — The  prospect  of  life  varies  according  to  the 
stage  and  site  of  the  disease  ;  when  it  is  confined  to  a  single  group  of 
glands,  two,  three,  or  even  more  years  may  elapse  before  death,  provided  pressure 
is  not  exerted  on  some  important  structure  such  as  the  trachea  or  bronchi. 

In  the  late  stage,  when  generahzation  has  taken  place,  the  end  is  nearer,  but 
considerable  variations  are  met  with.  Thus,  a  mediastinal  growth  may,  by 
mechanical  pressure,  precipitate  the  end.  Intrathoracic  and  intra-abdominal 
lymphadenoma  is  more  rapidly  fatal  than  widespread  superficial  glandular 
implication.  This  is  incidentally  shown  by  the  figures  given  belov/  in  connection 
with  the  bearing  of  relapsing  fever  on  the  prognosis.  Fever  of  one  form  or 
another  almost  always  occurs  in  the  course  of  the  disease,  and  generally  speaking 
its  presence  points  to  an  advanced  stage  with  generalization  of  the  disease. 
The  average  duration  of  life  after  the  onset  of  the  relapsing  type  of  fever  is  about 
seven  and  a  half  months  (Batty  ShawS),  but  cases  have  been  known  to  last  more 
than  a  year.  The  cases  which  present  the  relapsing  form  of  fever  appear  to  run 
a  more  rapid  course  than  others.  In  27  cases  of  lymphadenoma  with  relapsing 
fever  collected  by  McNalty,*  the  extremes  of  life  from  the  onset  of  the  glandular 
enlargement  were  five  weeks  and  four  years,  and  the  average  12-7  months  ;  or 
excluding  3  exceptional  cases  with  durations  of  two  and  a  half,  three,  and  four 
years,  9-3  months.  In  18  out  of  these  27  cases  in  which  the  superficial  glands 
were  enlarged,  the  average  duration  was  14-6  months,  or  excluding  the  3  cases 
of  exceptionally  long  duration,  ten  months.  In  7  cases  in  which  the  internal 
glands  only  were  affected,  the  duration  was  eight  months. 

Haemorrhages  and  a  grave  secondary  anaemia  show  that  the  end  is  near.  There 
seems  some  evidence  to  believe  that  a  decided  leucopenia  and  a  small  number  of 
platelets  in  the  blood  (Buntings)  indicate  a  late  stage  of  the  disease.  Pruritus, 
which  is  rather  a  rare  symptom,  has  appeared  to  me  to  be  associated  with  a 
rapid  course  of  the  disease.  10 

Disappearance  of  glandular  enlargement  is  not  necessarily  a  good  sign,  for 
the  disease  may  advance  in  the  internal  organs  while  the  superficial  lymphatic 
glands  are  disappearing.  Further,  although  the  amount  of  growth  left  is  small, 
the  patient  may  pass  into  an  extremely  aucemic  and  cachectic  condition  and  die. 
I  have  seen  this  after  prolonged  ;tr-ray  treatment.  The  appearance  of  complica- 
tions, of  which  tuberculosis  is  the  most  frequent,  renders  the  prognosis  very  grave. 

References. — ^Longcope,  System  of  Medicine  (Osier  and  McCrae),  1909,  vi,  475  ; 
^Yamasaki,  Zeits.  /.  Heilk.  1904,  xxv,  269  :  ^Karsner,  Arch.  Int.  Med.  Chicago,  1910, 
vi,  175;  *McNalty,  Quart.  Jour.  Med.  Oxford,  1911-12,  v,  76;  "Morton,  Proc.  Roy. 
Sac.  Med.  1910,  iii  (Electro-therapeut.  Scot.),  134  ;  ®Reid,  Proc.  Roy.  Soc.  Med.  1910, 
iii  (Electro-therapeut.  Sect.),  133  ;  'Pancoast,  Univ.  Penn.  Med.  Bull.  Philad.  1906-7, 
xix,  282  ;  ^H.  Batty  Shaw,  Edin.  Med.  Jour.  1901,  N.S.,  x,  501  ;  ^Bunting,  Johns 
Hop.  Hosp.  Bull.  1911,  xxii,  369  ;    ^"Rolleston,  Practitioner,  1911,  Ixxxvi,  505. 

H.  D.  Rolleston. 


INDEX     OF     PROGNOSIS 


LYMPHATIC  FISTULA,— (5ee  Thoracic  Duct,   Wounds  of.) 

MADURA  FOOT  (Mycetoma). — This  disease  usually  remains  localized, 
and  slowly  progresses  if  the  affected  part  is  not  amputated  ;  but  it  is  not  directly 
fatal,  and  in  only  one  recorded  case  has  it  become  generalized.       c.  W.  Daniels. 

MALARIA.-^Here  is  an  instance  where  the  prognosis  depends  largely  on 
early  diagnosis.  Most  of  the  deaths  occur  either  in  undiagnosed  cases,  or  in 
others  where  severe  complications  such  as  cerebral  crises  are  present  when 
treatment  is  commenced,  or  where  there  is  pre-existing  disease  or  organic 
change. 

In  England,  at  the  Albert  Dock  Hospital,  436  cases  of  malaria  have  been 
diagnosed  during  the  last  ten  years,  and  4  patients  have  died.  The  case- 
mortahty  was  therefore  o-gi  per  cent.  Of  these  four  cases,  two  were  not 
diagnosed  as  malaria  (being  thought  to  be  hsemorrhagic  pancreatitis,  and  asthma 
and  bronchitis,  respectively),  and  each  of  the  other  two  was  admitted  comatose 
in  a  cerebral  crisis.  Probably  if  the  diagnosis  had  been  made  early,  and  treatment 
commenced  at  once,  these  four  would  not  have  died. 

The  total  number  of  deaths  in  any  malarial  country  is  large.  In  some  of  these 
the  diagnosis  is  open  to  question  ;  in  many  there  has  been  no  antimalarial 
treatment ;   and  amongst  natives  the  majority  of  cases  are  neglected. 

A  certain  increase  should  perhaps  be  made  in  the  death-rate  owing  to  the  fact 
that  malaria  predisposes  to  intercurrent  diseases  such  as  dysentery  and  tubercu- 
losis, and  in  persons  with  a  fatty  or  a  poisoned  heart,  as  in  beri-beri,  it  may  by 
direct  toxic  effect  cause  a  fatal  termination  of  these  diseases.  Where  the  vessels 
are  atheromatous,  cerebral  haemorrhage  may  occur  as  a  result  of  the  high  blood- 
pressure  common  in  some  cases  of  malaria. 

Premature  labour  and  abortion  are  not  uncommon,  either  as  a  result  of  the 
disease  or  of  injudicious  treatment  with  quinine.  Still-births  and  high  infantile 
mortality  are  not  infrequent  in  parturient  women  with  malaria.       c.  W.  Daniels. 

MANIA. — [See  Mental  Diseases.) 

MEASLES. — The  most  important  points  to  which  attention  must  be  paid 
in  the  prognosis  of  measles  are — (i)  The  age  of  the  patient ;  (2)  The  presence  of 
certain  complications  ;  (3)  Certain  special  symptoms  ;  (4)  The  social  status  of 
the  patient ;    and  (5)   The  virulence  of  the  epidemic. 

I.  Age. — It  can  with  confidence  be  stated  in  general  terms  that  the  younger 
the  patient  the  worse  the  prognosis,  but  that  only  for  patients  under  two  years 
of  age  is  it  really  serious.  The  exact  gravity  of  the  prognosis  when  considered 
from  this  point  of  view  varies  with  the  character  of  the  epidemic  and  the  circum- 
stances of  the  patient.  The  fullest  figures  bearing  on  the  subject  are  those  from 
the  city  of  Aberdeen,  where  measles  was  a  notifiable  disease  for  the  twenty  years 
1883  to  1902.  During  that  period  40,374  cases  were  notified,  and  there  were 
1346  deaths.  For  all  ages  and  for  the  whole  period  the  fatahty  was  thus  3-3 
per  cent.  The  table  on  the  opposite  page  shows  the  fatality  at  different  age- 
periods.  From  this  it  is  seen  that  the  fatality  is  considerable,  and  highest  in 
infants  under  one,  and  next  high  in  those  between  one  and  two.  After  that  age 
it  drops  considerably,  and  remains  low  at  all  other  ages. 

It  is  possible  that  the  Aberdeen  notifications  contained  a  considerable  number . 
of  cases  of  rubella.     As  the  latter  disease  is  very  rarely  fatal,  its  inclusion  in 
notifications  of  measles  would  cause  the  fatality  from  this  disease  to  appear  to 
be  lower  than  it  really  is. 


MEASLES 


289 


Fatality  according  to  Age  (Aberdeen). 


Age 

Fatality 

Age 

Fatality 

per  cent 

per  cent 

Under  1 

13-9 

9-10 

0-6 

1-2 

lO'O 

10-11 

0-2 

2-3 

34 

11-12 

0-0 

3-4 

1-6 

12-13 

0-0 

4-5 

0-9 

13-14 

1-2 

5-fi 

0-7 

14-15 

0-0 

<;-7 

0-5 

15-25 

0-9 

7-8 

0-5 

25-60 

0-6 

8-9 

04 

GO  &  over 

0-0 

The  only  statistics  available  in  which  corrections  for  errors  of  diagnosis  have 
been  made  are  those  of  various  hospitals.  But  inasmuch  as  the  worst  cases*are, 
as  a  rule,  sent  to  hospital,  while  the  less  serious  are  treated  at  home,  the  fatality 
of  cases  treated  in  hospitals  is  usually  high.  The  following  table  shows  the  cases 
admitted  into  the  hospitals  of  the  Metropolitan  Asylums  Board  during  the  two 
years  igii  and  1912,  with  the  number  of  deaths  and  fatalitj'  per  cent: — j 


Fatality  according  to  Age  (Metropolitan  Asylums  Board). 


Age 

Cases 

Deaths 

Fatality 
per  cent 

Under  i 

667 

152 

22-7 

1-2 

1738 

366 

21-0 

2-3 

1355 

148 

10-9 

3-4 

1186 

96 

8-0 

4-5 

997 

61 

6-1 

Under    5 

5943 

823 

13-8 

5-10 

1325 

27 

2-0 

10-15 

114 

2 

1-7 

1.5-20 

27 

0 

0-0 

20  &  over 

49 

0 

0-0 

Total  . . 

7458 

852 

114 

The  figures  in  this  table  bear  out  the  statement  made  above  as  to  the  diminution 
of  the  fatality  with  the  increasing  age  of  the  patient. 

Sex  makes  no  difference  in  the  prognosis. 

2.  Complications. — Lung  Affections. — By  far  the  most  formidable,  as  well  as 
the  most  frequent,  complication  is  bronchopneumonia.  It  accounts  for  a  large 
majority  of  the  deaths  from  measles.  During  the  three  years  191T-12-13  there 
were  1882  cases  of  measles  under  treatment  at  the  Eastern  Hospital,  and  in  293, 
or  15-5  per  cent,  of  the  cases  bronchopneumonia  supervened.  Of  the  293  cases, 
210,  or  71-6  per  cent,  were  fatal.  Besides  these  there  were  17  fatal  cases  of 
bronchitis.  The  total  number  of  measles  deaths  for  the  three  years  was  292  ; 
so  that  in  777  per  cent  of  the  fatal  cases  death  was  due  to  acute  bronchitis  or 
bronchopneumonia.  These  figures  suffice  to  indicate  the  gravity  of  pulmonary 
complications. 

19 


290  INDEX     OF     PROGNOSIS 

Cancrum  Oris  and  Acute  Tuberculosis  are  extremely  serious.  Fortunately  they 
are  relatively  uncommon.  Chronic  and  latent  tuberculous  lesions  are  prone 
to  be  stirred  into  activity  by  an  attack  of  measles. 

Secondary  Inflammation  of  the  Fauces  should  be  regarded  with  apprehension. 
Not  infrequently  it  results  in  extensive  ulceration  and  septicaemia. 

Implication  of  the  Larynx  occurs  in  between  4  and  5  per  cent  of  the  cases.  The 
prognostic  significance  depends  on  the  period  during  which  it  arises.  There  is 
less  cause  for  alarm  when  it  occurs  during  the  initial  period,  before  the  appearance 
of  the  rash,  than  when  it  sets  in  as  the  latter  is  fading,  or  during  convalescence. 
The  laryngeal  symptoms  of  the  initial  period  are  usually  due  to  simple  laryngitis, 
and  in  many  cases  subside  when  the  rash  comes  out.  Late  laryngeal 
symptoms  betoken  either  diphtheria  or  laryngeal  ulceration,  both  of  which 
conditions  are  serious,  but  especially  the  former.  Indeed,  hardly  a  more  for- 
midable combination  of  acute  infectious  diseases  is  to  be  found  than  that  of 
diphtheria  and  measles. 

But  even  non-diphtheritic  inflammation  of  the  larynx  is  a  very  serious 
complication.  During  the  three  years  igii  to  19x3  there  were  78  cases  of 
laryngitis  or  ulceration  of  the  larynx  at  the  Eastern  Hospital.  Of  these,  30  were 
fatal,  or  38-4  per  cent.  In  a  considerable  number  of  the  cases  intubation  or 
tracheotomy  was  necessary.  Bronchopneumonia,  too,  is  not  uncommon  in  the 
laryngeal  cases.  The  incidence  of  laryngeal  comphcations  varies  in  different 
years.  The  78  cases  were  distributed  amongst  the  three  years,  as  follows  : 
1911,  30  cases  with  17  deaths  ;    1912,  28  with  6  deaths  ;    1913,  20  with  7  deaths. 

Eye  Affections. — The  eye  is  prone  to  become  inflamed  in  measles.  This 
complication  occurred  in  nearly  4  per  cent  of  the  cases  at  the  Eastern  Hospital. 
Usually  the  inflammation  is  limited  to  the  conjunctiva,  but  occasionally  the 
cornea  is  involved,  in  which  case  an  ulcer  and  an  opacity  may  result.  But  these 
sequelae  are  rarely  seen  in  cases  in  which  early  and  assiduous  treatment  has  been 
applied.  One  form  of  ophthalmia  is  particularly  dangerous — namely,  that  in 
which  not  only  the  conjunctiva,  but  also  the  eyehds  are  inflamed.  There  is 
usually  brawny  swelling,  and  the  lids  are  with  difficulty  separated.  These  are 
the  cases  in  which  loss  of  sight  results  sometimes,  even  though  every  attempt 
is  made  to  save  the  eye. 

Otitis  Media  occurs  in  from  11  to  14  per  cent  of  cases  treated  in  hospital.  The 
prognosis  is  much  the  same  as  in  scarlet  fever. 

3.  Special  Symptoms. — If  the  respiration  becomes  hurried  and  the  lips  and 
extremities  cyanotic  before  the  rash  comes  out,  the  prognosis  is  grave.  When 
convulsions  occur,  recovery  seldom  takes  place.  Should  pulmonary  symptoms 
not  clear  up  within  two  or  three  weeks  of  their  onset  (which  is  mostly  while  the 
rash  is  out) ,  tuberculous  disease  should  be  suspected.  Progressive  wasting  with 
pyrexia,  with  or  without  diarrhoea,  is  also  suggestive  of  the  same  disease. 
Frequent  vomiting  and  diarrhoea  are  ominous,  especially  if  they  come  on  early 
in  the  disease  and  are  accompanied  by  a  fall  of  temperature  and  other  signs  of 
collapse. 

4.  The  Social  Status  of  the  Patient. — It  is  a  matter  of  common  observation 
that  measles  is  much  more  fatal  amongst  the  poor  than  the  well-to-do.  Perhaps, 
indeed,  in  no  other  acute  infectious  disease,  with  the  exception  of  whooping- 
cough,  is  this  class-distinction  more  marked.  In  Aberdeen  it  was  found,  during 
the  twenty  years  aheady  referred  to,  that  the  fatality  varied  inversely  with  the 
number  of  rooms  occupied  by  the  famfly  in  which  the  cases  occurred.  Thus, 
in  one-roomed  houses  it  was  nearly  7  per  cent ;  in  two-roomed,  3  ;  in  three- 
roomed,  just  under  2  ;  and  in  four  and  five-roomed,  less  than  i.  The  average 
fatality  for  all  houses  was  24  per  cent. 


MELANOTIC     SARCOMA  291 

5.  Virulence  of  the  Epidemic. — The  effect  of  this  has  also  been  shown  by  the 
Aberdeen  figures.  In  that  city  the  fatality  from  measles  varied  from  o  to  25  per 
cent  in  different  years.  E.  W.  Goodall. 

MELANCHOLIA.— (See  Mental  Diseases.) 

MELANOTIC  SARCOMA. — The  prognosis  in  this  dreaded  form  of  mahgnant 
disease  has  been  depicted  as  black  as  the  characteristic  nodules  of  the  malady, 
a  view  which  requires  some  modification. 

Melanotic  sarcoma,  broadly  speaking,  arises  either  in  the  choroid  coat  of  the 
eye,  or  in  the  skin.  In  the  latter  situation  it  originates  either  from  a  congenital 
pigmented  mole,  or  in  rare  cases  from  punctured  wounds,  which  presumably 
carry  a  group  of  the  pigmented  connective-tissue  cells  of  the  skin  into  a 
situation  favourable  to  their  proliferative  activity. 

The  duration  of  life  in  melanotic  sarcoma  is  usually  about  two  to  three  years. 
The  disease  is  generally  painless  until  towards  the  end,  but  subcutaneous 
deposits  of  the  disease,  when  ulcerated,  become  painful.  The  patient  is  usually 
able  to  go  about  and  follow  his  occupation  without  any  feeling  of  illness  until 
a  few  rhonths  before  death.  Lymphatic  oedema  of  the  affected  limb  then  begins 
to  manifest  itself  if  the  disease  has  begun  on  one  of  the  extremities,  or  the 
deposits  in  the  internal  organs — and  especially  in  the  liver,  which  may  attain 
an  enormous  size — interfere  by  pressure  with  the  activities  of  the  vital  organs, 
and  cause  serous  effusions  which  are  the  usual  proximate  cause  of  death.  On 
the  whole,  melanotic  sarcoma  is  a  very  merciful  form  of  malignant  disease. 

As  stated  in  my  Hunterian  lectures  on  melanotic  growths,  I  have  obtained 
strong  microscopic  evidence  that  the  process  of  dissemination  in  malignant 
melanoma,  just  as  in  breast  cancer,  is  primarily  one  of  centrifugal  lymphatic 
permeation.  There  is,  it  is  true,  strong  evidence  from  the  results  of  necropsies 
that  in  many  cases  the  blood-vessels  are  the  channels  of  spread  in  the  later  stages 
of  dissemination.  The  crucial  point  to  settle  as  determining  the  prospects  of 
surgical  interference  in  malignant  melanoma  is  this  :  At  what  period  is  lymphatic 
dissemination  supplemented  or  replaced  by  blood  dissemination  ?  When  once 
viable  fragments  of  the  growth  are  launched  into  the  blood-stream  the  surgeon's 
hand  is  paralyzed,  and  the  patient  must  depend  entirely  on  the  natural  forces, 
always  inadequate,  and  frequently  altogether  absent,  which  tend  to  the  destruc- 
tion of  the  embolized  fragments. 

Fortunately  it  would  appear  that,  as  a  general  rule,  blood  invasion  does  not 
take  place  at  an  early  stage.  This  is  indicated  prima  facie  by  the  comparatively 
long  average  duration  of  the  disease,  which  has  been  estimated  at  three  years  ; 
if  malignant  cells  reach  the  blood  in  the  early  stage  of  the  disease,  the  natural 
powers  of  resistance  must  inhibit  their  further  development,  or  obviously  the 
patient  would  succumb  within  a  few  months.  In  the  second  place,  cases  of 
death  from  intercurrent  disease  occur,  in  which  lymphatic  dissemination 
sufficiently  widespread  to  be  inoperable  is  seen,  unaccompanied  by  evidence 
of  blood  dissemination.  Lastly,  most  extensive  lymphatic  distribution  of  the 
disease  may  take  place  in  the  glands,  the  subcutaneous  tissues,  and  upon  the 
serous  membranes,  without  any  of  the  nodular  visceral  metastases  which  are 
the  usual  result  of  blood  embolism.  In  the  museum  of  Guy's  Hospital  there  is 
a  specimen  which  bears  very  directly  on  this  point.  It  is  a  kidney,  itself  entirely 
free  from  disease  so  far  as  the  naked  eye  can  see,  but  embedded  in  a  mass  of 
melanotic  growth  which  is  replacing  the  perinephric  fat.  It  appears  certain  that, 
as  frequently  happens  in  breast  cancer,  the  perinephric  growth  originated  from 
malignant  infection  of  the  lumbar  glands.     If  this  is  the  case,  it  is  evident  that 


292  INDEX     OF     PROGNOSIS 

widespread  lymphatic  dissemination  may  occur  in  melanotic  sarcoma,  without 
obvious  evidence  in  the  kidneys  of  embohc  blood  invasion. 

To  sum  up,  pathology  indicates  that  if  the  operation  for  melanotic  sarcoma 
is  rightly  planned,  its  prospects  should  not  be  so  hopeless  as  is  generally  assumed. 

The  principles  upon  which  the  excision  of  a  mahgnant  melanoma  should  be 
carried  out  are,  in  my  opinion,  as  follows  :  A  circular  incision  should  be  made 
through  the  skin  round  the  tumour,  at  what  is  judged  by  present  standards  to  be 
a  safe  and  practicable  distance.  The  incision,  situated  as  a  rule  about  an  inch 
from  the  edge  of  the  tumour,  should  be  just  deep  enough  to  expose  the  sub- 
cutaneous fat.  If  necessary,  two  radial  hnear  incisions  extending  from  the 
circular  one  should  be  made  on  opposite  sides  of  the  tumour  in  order  to  facihtate 
the  elevation  of  the  sldn  flaps,  which  forms  the  next  step.  The  skin,  with  a  thin 
attached  layer  of  subcutaneous  fat,  is  now  to  be  separated  from  the  deeper 
structures  for  about  two  inches  in  all  directions  round  the  skin  incision.  At  the 
extreme  base  of  the  elevated  skin  flaps  a  ring  incision  down  to  the  muscles 
surrounds  and  isolates  the  area  of  deep  fascia  and  overlying  deeper  subcutaneous 
fat  to  be  removed.  The  fascial  area  is  next  to  be  dissected  up  centripetaUy 
from  the  muscles  beneath,  to  a  Hne  which  corresponds  vnth.  that  of  the  circular 
skin  incision.  Finally,  the  whole  mass  with  the  growth  at  its  centre  is  removed 
by  scooping  out  with  a  knife  a  circular  area  of  the  muscle  immediately  subjacent 
to  the  growth.  The  edges  of  the  wound  are  to  be  brought  together  as  conveni- 
ence dictates. 

Writing  in  1903,  Eve^  said  :  "  The  removal  of  the  nearest  chain  of  lymphatic 
glands,  whether  palpably  enlarged  or  not,  should  never  be  omitted  ;  for  it  may 
be  taken  as  a  matter  of  certainty  that  in  a  great  majority  of  cases  they  are 
infected."  In  the  same  paper.  Eve  enforces  this  lesson  by  recording  a  case  of 
melanoma  of  the  palm  in  which,  although  the  axillary  glands  were  not  palpably 
enlarged,  they  were  infected  even  to  the  naked  eye.  Yet  Acton,^  writing  in 
1905,  found  in  nearly  every  case  of  which  the  records  were  available,  that  the 
primary  growth  was  removed  and  the  lymphatic  glands  were  left. 

Admitting  the  imperative  need  for  removal  of  the  lymphatic  glands  as  a  part 
of  the  first  operation,  it  must  be  remarked  that  in  cases  which  show  palpable 
enlargement  of  these  glands,  simple  excision  of  the  glands  is  hkely  to  be  quite 
useless.  I  have  shown  that  permeation  of  the  lymphatic  plexus  of  the  deep 
fascia  soon  takes  place  around  the  infected  glands,  just  as  it  occurs  round  the 
primary  tumour.  The  excision  of  the  glands  must  therefore  be  carried  out  on 
exactly  the  same  principles  as  the  excision  of  the  primary  tumour — that  is  to 
say,  a  large  circular  area  of  the  surrounding  deep  fascia  must  be  exposed,  dissected 
up  from  its  circumference  towards  the  infected  glands,  and  removed  in  one  piece 
with  them.  In  late  cases  it  may  even  be  right  to  remove  an  area  of  skin  over  the 
infected  glands,  but  such  cases  are  probably  inoperable.  Lastly — and  this  is 
most  important — the  apparently  healthy  set  of  glands  above  those  obviously 
enlarged  should  be  completely  removed. 

The  case  which  follows  illustrates  the  successful  application  of  these  principles. 

Miss  C,  age  40,  was  sent  to  me  by  Dr.  Burstal,  of  Staines,  on  October  21,  1909.  In 
Septem.ber,  1907,  Dr.  Moreton  Palmer  removed  an  ulcerated  papilloma  which  had  been 
present  on  the  dorsum  of  the  left  -wTist  for  three  or  four  years.  In  September,  igo8, 
some  small  lumps  were  removed  just  above  the  epitrochlear  gland.  These  lumps 
were  subcutaneous,  and  were  not  glandular.  A  week  or  two  later,  a  small  dark  nodule 
appeared  just  below  the  incision.  It  was  removed  under  local  anaesthesia,  and  was 
reported  by  the  Clinical  Research  Association  as  a  malignant  melanoma.  Subsequently, 
the  patient  suffered  much  pain  in  the  bicipital  region,  thought  to  be  due  to  an  involve- 
ment of  nerves  in  the  scar.  On  examination,  I  found  a  vague  induration  running  up 
the  brachial  vessels  about  the  middle  of  the  upper  arm,  midway  between  the  axilla  and 
the  scar  of  the  second  operation,  and  it  appeared  probable  that  the  growth  was  recurrent 


MELANOTIC     SARCOMA  293 

in  this  situation ;  moreover,  a  large  gland,  nearly  as  big  as  a  chestnut,  could  be  felt  in 
the  axilla.  I  therefore  advised  a  thorough  operation,  which  should  include  removal  of 
the  supraclavicular  glands,  clearing  of  the  axilla,  and  excision  of  the  deep  fascia  extending 
from  the  axilla  almost  to  the  elbow.  The  patient  consented  to  undergo  the  operation, 
and  was  admitted  to  the  Bolingbroke  Hospital.  A  semilunar  flap  of  skin,  involving 
most  of  the  inner  aspect  of  the  arm,  was  turned  backwards,  and  the  deep  fascia  was 
widely  removed,  with  exposure  of  the  brachial  vessels  and  accompanying  nerves.  The 
axilla  was  next  opened  by  a  prolongation  into  its  fornix  of  the  first  incision,  and  was 
completely  cleared  of  its  fat  and  glands,  which  were  removed  in  continuity  with  the 
deep  fascia  of  the  inner  side  of  the  arm.  The  supraclavicular  triangle  was  now  cleared 
of  its  fat  and  glands  through  a  separate  incision.  The  patient  made  a  good  recovery 
from  the  operation. 

About  a  year  later,  a  recurrent  nodule  appeared  over  the  lower  part  of  the  triceps  at 
the  back  of  the  arm.  It  was  excised  on  December  15,  1909,  and  on  section  was  a  typical 
sarcoma,  unpigmented  and  degenerate  at  the  centre.  (It  is  well  known  that  unpigmented 
metastases  are  not  rare  in  melanotic  sarcoma.)  Since  this  time  the  patient  has  remained 
well,  and  the  neuralgic  pains  from  which  she  suffered  in  the  arm  have  greatly  improved, 
especially  since  a  visit  to  Sidmouth,  where  she  had  hot  sea-bathing  treatment. 

The  absence  of  any  sign  of  recurrence  up  to  the  present  time,  a  period  of  over  four 
years,  encourages  me  to  hope  that  in  this  case  a  permanent  cure  has  been  obtained. 

In  this  connection  I  may  repeat  what  I  said  in  my  Hunteriau  lectures  in  1907  : 
"  The  methods  still  employed  in  dealing  with  melanotic  growths  of  the  skin  are 
precisely  those  which  years  ago  gave  such  deplorably  bad  results  in  the  treatment 
of  carcinoma  of  the  breast.  Formerly  the  tumour,  with  a  small  circumferential 
area  of  skin,  was  cut  out  from  the  breast,  and  the  axillary  glands  were  removed, 
if  at  all,  only  when  palpably  enlarged.  Even  when  the  glands  were  excised,  the 
surrounding  zone  of  permeated  lymphatics  in  the  breast,  in  the  deep  fascia, 
and  in  the  muscles,  w-as  left  intact  to  reproduce  the  disease.  Nowadays,  the 
improved  operation  for  breast  cancer  produces  prolonged  or  permanent  immunity 
in  about  50  per  cent  of  cases.  And  upon  the  evidence  I  have  laid  before  you, 
I  venture  to  predict  that  the  apphcation  of  more  thorough  and  scientific  methods 
to  the  surgery  of  cutaneous  melanomata  will  produce  a  corresponding,  though 
perhaps  a  smaller,  improvement  in  the  results  of  operation." 

I  trust  that  the  case  I  have  recorded  is  the  beginning  of  the  fulfilment  of  the 
prediction  then  made,  though,  owing  to  the  fortunate  rarity  of  the  disease,  the 
evidence  can  only  accumulate  very  slowly. 

Only  one  other  opportunity  has  occurred  to  me  of  applying  the  principles 
w-hich  I  advocate  in  the  treatment  of  melanotic  sarcoma. 

The  case  was  that  of  a  middle-aged  man  lying  in  the  inoperable  cancer  wards  of  the 
Middlesex  Hospital,  with  a  small,  non-pigmented,  pedunculated  growth  of  the  foot,  and 
a  mass  of  confluent  and  adherent  melanotic  inguinal  glands.  I  had  no  sanguine  expecta- 
tion that  he  would  escape  local  recurrence  after  the  removal  of  these  glands,  but  since 
only  slightly-enlarged  glands  could  be  felt  above  Poupart's  ligament,  I  thought  it  worth 
while  to  attempt  radical  treatment.  After  removing  the  primary  growth,  I  excised  the 
inguinal  glands  with  a  large  area  of  fascia.  I  then  divided  Poupart's  ligament,  and 
removed  the  glands  along  the  external  iliac  vessels  nearly  as  high  as  the  bifurcation  of  the 
aorta.  But  even  the  highest  glands  which  I  could  reach  already  showed  signs  of  early 
malignant  deposit,  and  it  was  impossible  to  carry  out  the  principle  which  I  believe  to  be 
so  important,  namely,  the  removal  of  the  apparently  uninfected  set  of  glands  above 
those  enlarged.  I  was  not  surprised  that  this  patient  retmrned  a  few  months  later  with 
inoperable  recurrence  in  the  region  of  Poupart's  ligament. 

To  sum  up,  the  prognosis  in  melanotic  sarcoma  is  not  nearly  so  bad  as  it  has 
been  represented,  provided  that  the  disease  is  recognized  early,  and  that  it  is 
operated  upon  on  the  lines  indicated  by  the  pathological  evidence  of  its  mode  of 
spread. 

References. — ^  Eve,  "  A  Lecture  on  Melanoma,"  Practitioner,  1903,  Feb. ;  ^  H.  W. 
Aeton,  Middlesex  Hosp.  Jour.  1905. 

W.    Sampson  Handlcy. 


294  INDEX     OF     PROGNOSIS 

MENINGITIS. 

Meningococcal  Meningitis  (sporadic). — In  this  form,  where  the  diagnosis  can 
generally  be  clinched  by  the  demonstration  in  the  cerebrospinal  fluid  of  the 
characteristic  diplococcus,  the  prognosis  as  to  life  is  relatively  more  favourable 
than  in  other  forms  of  meningitis.  Thus,  in  the  94  cases  collected  by  Lee  and 
Bachow,  50  per  cent  of  the  patients  admitted  to  hospital  survived ;  but,  of  these, 
only  some  15  per  cent  recovered  completely,  the  rest  being  left  with  hydro- 
cephalus, blindness,  or  varying  degrees  of  mental  deficiency,  sometimes  amounting 
to  idiocy. 

The  results  of  intrathecal  injection  of  antimeningococcal  serum  are  less 
striking  than  in  the  epidemic  variety  of  the  disease.  Nevertheless,  lumbar 
puncture — by  relieving  the  intracranial  pressure — and  the  administration  of  the 
above-mentioned  serum,  when  available,  will  sometimes  turn  the  balance  and 
may  save  a  patient  who  would  otherwise  die. 

The  prognosis  as  to  the  future  mental  condition  of  those  patients  who  survive 
should  be  guarded.  Even  after  an  apparently  complete  recovery  from  all  the 
meningeal  symptoms,  it  may  be  found  that  the  child's  subsequent  mental 
development  is  arrested  or  delayed.  Further,  a  considerable  proportion  of  the 
cases  which  survive  develop  hydrocephalus,  probably  due  to  adhesive  obstruction 
in  the  foramen  of  Monro  or  in  the  other  foramina  in  the  neighbourhood  of  the 
fourth  ventricle,  thereby  preventing  the  downward  flow  of  fluid  from  the  ventricles 
into  the  spinal  theca.  Other  patients,  again,  become  permanently  blind  or 
deaf  from  inflammatory  changes  in  the  optic  or  auditory  nerves. 

Meningococcal  Meningitis  (epidemic). — The  prognosis  in  cases  of  this  type, 
untreated  by  serum,  is  extremely  bad.  According  to  the  statistics  of  Flexner, 
the  mortality  is  usually  from  80  to  90  per  cent,  and  never  less  than  70  per  cent. 
Since  the  introduction  of  serum  treatment  by  intrathecal  injection,  however, 
the  gross  mortality  of  cases  thus  treated  has  fallen  to  a  remarkable  extent. 
Thus,  out  of  1295  serum- treated  cases  collected  by  Flexner,  893  recovered  and 
402  died,  a  mortality  of  31  per  cent.  The  earlier  in  the  disease  the  specific  treat- 
ment is  begun,  the  better  are  the  prospects,  as  shown  by  the  following  table  of 
121 1  cases  :— 

Mortality  According  to  Time  of  Serum  Treatment. 


Period  of  Disease 

Number  of 
Cases 

Mortality 
per  cent 

Within  first  three  days 
Fourth  to  seventh  day 
Later  than  seventh  day 

199 
346 
666 

18 
27 

;3(; 

The  mortality  amongst  infants  under  two  years  of  age  is  usually  very  higli, 
rarely  being  less  than  90  per  cent,  according  to  Flexner.  But  of  125  serum- 
treated  infants  under  one  year,  63  recovered  and  62  died  ;  of  21  infants  injected 
within  the  first  seven  days,  1 7  recovered  and  only  4  died,  a  mortality  of  less  than 
20  per  cent. 

Whereas  recovery  is  a  gradual  process,  lasting  about  four  weeks,  in  the  small 
proportion  of  epidemic  cases  which  spontaneously  survive:  in  serum- treated 
cases,  on  the  other  hand,  recovery  by  crisis  is  not  uncommon,  and  the  duration 
of  the  disease  averages  only  about  eleven  days. 

Pneumococcal  Meningitis,  etc. — Pneumococcal  meningitis  may  occur  as  a 
primary  malady,  or  it  may  be  secondary  to  pneumococcal  infection  of   other 


MENINGITIS  295 


parts  of  the  body,  especially  after  empyema  or  otitis  media.  Untreated  cases 
are  practically  always  fatal.  Lumbar  puncture  undoubtedly  relieves  symptoms, 
and  may  in  some  cases  turn  the  balance  in  favour  of  recovery.  The  same 
remark  applies  to  Streptococcal  and  Staphylococcal,  and  also  to  Influenzal,  Typhoidal , 
and  Gonococcal  meningitis.  I  myself  observed  a  case  of  gonococcal  meningitis 
in  a  young  man  aged  twenty-nine,  in  whom,  three  weeks  after  the  urethral 
infection,  gonococcal  arthritis  developed  in  the  knee  and  hand.  Three  weeks 
later — i.e.,  six  weeks  after  the  original  infection, — he  developed  all  the  signs 
of  meningitis.  The  cerebrospinal  fluid  was  turbid,  with  a  large  deposit  of  pus. 
Antigonococcal  serum  was  injected  intrathecally,  and,  on  three  subsequent 
occasions  within  a  week,  antimeningococcal  serum.  After  a  temporary  relapse, 
the  patient  ultimately  made  a  complete  recovery  in  about  three  months. 

Tuberculous  Meningitis. — Here  the  prognosis  is  always  grave.  Once  the 
diagnosis  has  been  established,  by  the  presence  of  headache,  vomiting,  convul- 
sions, stupor,  by  the  occurrence  of  a  pleocytosis  of  the  cerebrospinal  fluid,  and, 
most  conclusive  of  all,  by  the  discovery  of  tubercle  bacilli  in  the  fluid,  we  must 
be  very  guarded  in  our  prognosis.  The  prospects  of  recovery  depend  upon 
various  factors.  If  the  disease  be  limited  to  a  small  part  of  the  meninges,  and 
if  there  be  no  extension  into  the  substance  of  the  brain,  there  is  still  a  possibility 
of  recovery.  If,  however,  the  meningitis  be  widespread,  and  accompanied  by 
numerous  signs  of  focal  brain  affection,  the  hope  of  recovery  is  almost  nil.  The 
occurrence  of  glycosuria  is  of  bad  omen  ;  when  present,  it  generally  presages 
death  within  two  or  three  days. 

In  making  our  prognosis  in  any  individual  case  of  meningitis,  from  whatever 
cause,  we  have  to  bear  in  mind  that  the  immediate  causes  of  death  are  two  in 
number  :  first,  mechanical  distention  of  the  cerebral  ventricles  (acute  hydro- 
cephalus) ;  and  second,  toxaemia  resulting  from  the  products  of  the  infective 
organism.  The  toxaemic  element,  unfortunately,  is  not  at  present  directly 
amenable  to  treatment ;  but  if  this  factor  be  not  too  intense,  we  may,  by  relieving 
the  mechanical  distention,  sometimes  save  the  patient's  life.  This  is  best  done 
by  early  and  repeated  lumbar  punctures.  After  withdrawing  cerebrospinal 
fluid  until  the  intrathecal  pressure  falls  to  normal,  we  generally  obtain  distinct 
improvement  in  the  clinical  symptoms,  so  that  the  coma  or  stupor  clears  up, 
temporarily  at  least,  and  the  headache  and  vomiting  are  relieved.  By  repeated 
lumbar  punctures  at  intervals  of  one  or  two  days,  life  may  thus  be  prolonged,  and 
cure  may  even  result.  I  may  quote  a  case  of  my  own,  a  young  man  of  twenty- 
two,  with  headache,  vomiting,  stupor,  head  retraction,  absent  knee-jerks,  etc., 
in  whom  a  patch  of  chronic  lupus  on  one  leg  gave  clinical  evidence  of  tuberculous 
infection,  and  in  whom  the  cerebrospinal  fluid  contained  no  fewer  than  3467 
lymphocytes  per  c.mm.  Repeated  lumbar  punctures,  five  in  all,  about  once  a 
week,  produced  not  only  disappearance  of  all  the  clinical  symptoms,  but  the 
pleocytosis  of  the  cerebrospinal  fluid  fell  successively  to  827,  787,  36,  and  16  cells 
per  c.mm.,  and  the  patient  made  a  perfect  recovery.  Such  cases,  it  must  be 
admitted,  are  the  exception,  but  the  fact  that  they  do  occur  must  modify  the 
view  hitherto  almost  universally  held,  that  the  result  must  certainly  be  fatal, 
once  the  diagnosis  of  tuberculous  meningitis  is  established. 

Meningism  is  a  condition  in  which  the  patient,  usually  a  child,  either  during 
the  course  of  some  specific  fever  or  in  any  febrile  condition,  develops  many  of  the 
clinical  phenomena  of  meningitis,  but  where  the  cerebrospinal  fluid  withdiawn 
by  lumbar  puncture  contains  neither  excess  of  cells  nor  organisms.  It  is  more 
frequent  in  children  with  a  tuberculous  diathesis,  and  may  thus  raise  the  suspicion 
of  tuberculous  meningitis.  The  symptoms  rapidly  clear  up  after  the  lumbar 
puncture.  Ptirves  Stewart. 


296  INDEX     OF     PROGNOSIS 

MENTAL  DISEASES. — Prognosis  in  mental  diseases  is  afiected  not  only 
by  the  nature  and  causes  of  the  particular  maladies,  but  also  largely  by  the 
special  anatomical  construction  and  physiological  functions  of  the  brain.  A 
correct  prognosis  is  easj^  in  some  forms  of  disease,  for  instance,  in  many  forms  of 
skin  disease.  But  in  dealing  with  an  organ  such  as  the  brain,  the  most  important 
in  the  bod}'-  in  its  constitution  and  functions,  the  most  highly  integrated,  the 
most  complex,  and  the  most  sensitive  to  the  effects  of  every  environment 
outside  the  body,  and  to  everything  that  takes  place  in  its  own  working,  it 
would  be  unreasonable  to  expect  a  very  definite  prognosis  in  most  cases  when 
it  becomes  diseased  or  disordered.  Especially  when  its  highest  function  of 
mind  is  disturbed,  the  difficulty  of  saying  whether  it  wiU  again  resume  its  normal 
condition  is  often  extreme.  In  addition  to  physical  conditions  of  disorder,  we 
are  face  to  face  with  an  entirely  different  set  of  conditions,  viz.,  states  of  con- 
sciousness, intelligence,  emotion,  and  passion.  Disturbance  of  each  of  these 
may  not  only  be  a  result  of  brain  disease,  but  they  may  be  its  causes,  and  they 
may  also  act  as  a  means  of  cure.  Mental  diseases  are  unquestionably  the 
most  difficult  department  of  medicine.  The  higher  forms  of  the  brain  cell, 
being  the  vehicle  of  mind,  are  Nature's  last  and  greatest  effort  in  the  evolutionary 
process  which  has  been  going  on  during  the  past  aeons  of  time.  The  full  know- 
ledge, treatment,  and  cure  of  these  will  be  the  high-water  mark  of  medicine. 
Every  such  cell  carries,  in  its  molecular  structure  and  in  its  biochemical  mode 
of  action,  the  organic  memories  of  its  ancestral  cells,  and  with  those  memories 
it  becomes  subject  to  ancestral  reversions  and  weaknesses.  How  subtle  and 
imponderable  must  be  the  changes  which  cause  the  mild  emotional  depression 
perhaps  felt  in  the  morning  and  gone  within  an  hour  !  Yet  that  depression 
in  a  more  marked  form  may  constitute  a  mental  disease.  The  human  brain  is 
a  cosmos  in  which  are  represented  the  working  and  the  condition  of  every  other 
organ  in  the  body.  There  are  few  diseases  to  which  the  mind  is  subject  where 
some  organ  or  function  of  the  body  is  not  also  disturbed,  and  there  are  many 
cases  where,  as  a  result  of  mental  disease,  we  have  also  peripheral  bodily  disturb- 
ances. There  are,  however,  some  cases  of  mental  disease  where  we  cannot, 
by  anAJ-  means  at  present  at  our  disposal,  discover  any  bodily  symptom  what- 
ever, the  mind  cell  alone  seeming  to  be  affected,  and  where  the  prognosis  seems 
to  depend  on  mental  means  of  cure  alone.  Prognosis  in  such  cases  must  depend 
on  reactions  to  mental  stimuli,  but  it  may  be  said  generally  that  prognosis 
depends  chiefly  on  bodil}'  reactions  to  environment,  diet,  and  medicine.  If 
those  reactions  are  favourable  and  there  is  no  organic  brain  disease,  the  prognosis 
is  usually  good.  The  subjective  state  of  the  patient  must  always  be  taken  into 
account,  and  especially  his  feelings  of  optimism,  his  belief  that  he  will  overcome 
the  disease,  and  his  power  of  will  to  fight  against  it.  Personal  equations  of 
all  sorts  come  in  both  in  regard  to  the  doctor  and  the  nurses,  as  well  as  the 
patient  himself,  for  cure  and  prognosis. 

The  prognosis  in  mental  disease  must  depend  chief!}'  on  the  twelve  following 
considerations,  namely  : — 

1.  The  causes  of  the  disease. 

2.  Its  form  and  symptoms. 

3.  Its  previous  duration. 

4.  The  brain  heredity  of  the  patient. 

5.  The  possibilit}'  of  response  and  reaction  of  the  mental  and  bodily  symptoms 
to  suitable  treatment,  especially  to  the  restoration  of  sleep. 

6.  The  sequence  of  the  mental  and  bodily  changes  that  have  taken  place 
during  the  attack. 

7.  The  period  of  life  of  the  patient. 


MENTAL     DISEASES  297 


8.  The  existence  or  not  of  signs  of  organic  disease  in  the  brain  cells. 

9.  The    existence    or    not   of    certain   abnormal   bodily  conformations   and 
stigmata. 

10.  The  tendency  or  not  that  may  exist  to  relapse  and  recurrence  of  the 
symptoms. 

11.  The  completeness  or  incompleteness  of  the  improvement  in  the  attack 
under  treatment. 

12.  The  temperament  and  race  of  the  patient. 

It  need  hardly  be  said  that  in  almost  every  case  both  the  mental  and  bodily 
symptoms  present  at  the  time,  and  that  have  existed  during  the  attack,  must 
be  taken  into  account  in  any  attempt  to  predict  the  course  and  duration  of 
unsoundness  of  mind.  In  one  case  the  mental  symptoms  will  give  better 
indications  for  prognosis,  while  in  another  the  bodily  symptoms,  or  the  absence 
of  them,  will  be  more  to  be  relied  on. 

The  really  scientific  study  of  mental  diseases  onh?-  began  in  the  end  of  the 
eighteenth,  and  the  first  part  of  the  nineteenth,  centuries.  The  physiology 
of  the  brain  and  its  minute  structure  were  only  able  to  be  scientifically  studied 
well  into  the  nineteenth  centurj^  and  without  the  knowledge  gained  by  this 
study  a  scientific  psj^chiatry  could  not  have  been  attained.  The  classification 
of  mental  diseases  and  defects  was  at  first  founded  on  mental  symptoms  alone. 
It  consisted  of  four  varieties,  namely  :  mania,  or  states  of  mental  exaltation  ; 
melancholia,  or  states  of  emotional  depression  ;  dementia,  or  conditions  of 
permanent  mental  enfeeblement  coming  on  in  a  brain  that  had  once  been 
normal ;  and  idiocy,  or  congenital  forms  of  mental  weakness.  During  the 
latter  part  of  the  nineteenth  century  an  enormous  number  of  varieties  of  mental 
disease  have  been  segregated,  their  foundation  in  different  cases  being  etio- 
logical, pathological,  and  psychological.  Some  of  these  varieties,  like  general 
paralysis,  must  be  permanent.  Many  of  them  are  obviously  transitory  and 
experimental.  Prognosis  must  depend  to  a  large  extent  on  a  true  classification, 
where  that  is  possible,  and  in  the  present  article  I  shall  adopt  the  varieties 
which  seem  to  me  to  have  a  scientific  and  practical  basis. 

Early  in  the  scientific  study  of  mental  diseases  attempts  were  made  in  this, 
country,  on  the  Continent,  and  in  America,  to  draw  up  statistical  tables 
showing  the  number  of  recoveries,  the  number  of  deaths,  the  liability  to  relapse, 
and  the  duration  of  the  attacks,  but  in  all  these  insanity  was  regarded  as  a  whole, 
and  its  forms  and  varieties  were  not  taken  account  of.  The  science  of  n?edical 
statistics  was  then  in  its  infancy,  and  the  registers  of  the  various  existing  mental 
hospitals  were  very  imperfectly  kept,  while  there  were  no  available  facts  to  be 
obtained  from  records  of  private  practice.  Esquirol  in  France,  Jacobi  in 
Germany,  and  especially  Thurnam  in  England,  were  the  pioneers  in  the 
statistical  department  of  prognosis  in  mental  diseases.  Farr  helped  greatly 
by  pointing  out  the  errors  of  previous  writers  and  in  laying  the  foundatipn 
of  general  medical  statistics  on  scientific  principles.  The  figures  and  the  general 
results  of  these  authorities  need  not  be  discussed  in  detail  in  this  article,  as 
the  chief  aim  of  this  work  is  not  statistical  but  clinical,  and  to  help  the  practi- 
tioner of  medicine.  Thurnam  sums  up  the  general  results  of  the  treatment 
of  insanity  in  institutions  in  his  time,  that  is,  about  1845,  in  this  way  :  "  A 
proportion  of  much  less  than  40  per  cent  of  recoveries  on  the  admissions  is, 
under  ordinary  circumstances,  to  be  regarded  as  a  low  proportion,  and  one 
much  exceeding  45  per  cent  is  a  high  proportion."  He  says,  in  regard  to  the 
mortality  rate  among  the  mentally  afflicted,  "  a  mortality  that  exceeds  9  or  10 
per  cent  is  decidedly  unfavourable,"  and  one  wliich  is  less  than  7  per  cent  is 
"highly  favourable,"  in  asylums  where  all  classes  are  treated.    In  regard  to  pauper 


298  INDEX     OF     PROGNOSIS 

asylums  a  mortality  which  exceeds  12  or  13  per  cent  is  "a  very  unfavour- 
able one,"  and  one  which  is  much  less  than  10  per  cent  is  "highly  favourable." 
Since  that  time  the  rate  of  mortality  has  remained  nearly  stationary,  in  spite 
of  the  fact  that  far  more  cases  of  senile  breakdown  and  organic  brain  disease 
with  resulting  mental  symptoms  are  now  certified  as  insane.  My  personal 
experience  of  the  recovery  rate  in  11,346  patients  treated  by  me  in  the  Roj-al 
Edinburgh  Asylum  during  the  thirty  3'ears  1874-1903,  was  that  39-4  per  cent 
of  them  recovered.  They  included  every  variety  of  mental  disease  and  defect 
which  can  be  certified  under  the  Scottish  Lunacy  Laws  as  unsoundness  of  mind 
or  idiocy,  but  the  number  of  cases  of  idiocy  or  congenital  imbecility  was  com- 
paratively small.  I  shall  have  in  the  course  of  this  article  to  refer  to  the  recovery 
rate  in  the  various  forms  of  mental  disease  which  have  been  under  my  care 
in  two  mental  hospitals  and  in  my  private  practice.  The  figures  from  the 
Royal  Edinburgh  Asylum  have  this  advantage  over  those  of  county  asylums 
and  the  registered  hospitals  of  England,  that  they  comprise  the  whole  population 
and  are  not  confined  to  the  rate-paid  class  as  in  the  county  borough  and  district 
asylums,  or  the  class  in  a  better  social  position  who  can  afford  to  pay  for  their 
maintenance  as  in  the  registered  hospitals.  They  also  have  this  advantage, 
that  they  comprise  the  period  (fifty  years  ago)  when  the  number  and  variety 
of  persons  counted  as  technically  insane  and  certified  as  such  for  institutions, 
was  more  restricted  than  in  the  older  times,  and  also  the  more  recent  years, 
when  undoubtedly  an  extension  has  been  given  to  the  meaning  of  the  term 
'  insanit}'.'  Fifty  years  ago,  before  the  Government  grant  was  given  towards 
the  partial  maintenance  of  every  pauper  patient,  it  was  not  so  common  as  it 
is  now  to  send  to  mental  hospitals  patients  who  suffered  from  various  fornis 
of  senile  decaj-,  paralysis,  and  other  incurable  brain  diseases.  This  is  now  done 
for  two  reasons  :  first,  the  great  convenience  and  the  real  benefit  to  such  help- 
less persons  of  being  properly  treated  in  the  hospital  wards  of  county  asylums  ; 
second,  the  change  of  opinion  that  has  taken  place  in  regard  to  its  being  a 
discredit,  if  not  a  disgrace,  to  have  a  relation  in  a  mental  hospital.  The  general 
effect  of  this  change  of  opinion  and  practice  has  been  to  reduce  the  percentage 
of  recoveries  in  British  institutions.  There  has  been,  however,  another  tendency 
in  the  opposite  direction,  namelj-,  to  send  cases  at  an  earlier  period  of  their 
disease,  and  to  send  more  transitory  and  alcoholic  cases,  both  of  whom  are  apt 
to  recover  soon.  In  considering  the  statistics  of  institutions  and  of  certified 
patients,  this  fact  must  be  kept  in  mind,  that  mental  disease  in  all  civilized 
countries  is  not  looked  at  and  defined  through  the  clinical  symptoms  present 
and  from  a  scientific  point  of  view,  but  largely  through  the  provisions  of  the 
Lunacy  Statutes.  In  this  respect  mental  disease  differs  from  all  other  diseases. 
An  important  series  of  tables  are  given  in  the  Reports  of  the  Scottish  Board 
of  Lunacy  for  1S98  and  1913  (the  40th  and  55th  Reports),  showing  the 
'  progressive  history '  of  385S  patients  for  fifteen  3-ears  after  admission  into 
mental  hospitals.  These  throw  a  valuable  but  not  a  complete  light  on  the 
prognosis  of  mental  diseases,  in  regard  to  recovery  and  mortality.  Of  the 
patients  of  all  classes,  ages,  and  forms  of  mental  disease,  admitted  into  Scottish 
asylums  in  1868  and  1S98,  the  chief  results  in  the  fifteen  years  are  as  follows  : 
there  were  2252  '  recoveries,'  or  58-6  per  cent  of  the  whole.  But  those  included 
repeated  recoveries  in  many  of  the  patients.  In  fact,  there  were  1230  readmis- 
sions  to  the  institutions,  most  of  which  resulted  from  relapses  into  mental 
disease,  and  some  had  such  relapses  several  times.  Some  of  the  readitussions 
were,  no  doubt,  of  the  781  who  had  left  the  institution  not  recovered.  On 
the  hypothesis  that  one-fourth  of  the  '  recoveries  '  had  been  those  of  relapsed 
cases  or  of  the  previously  discharged  non-recovered,  it  would  show  a  recover)' 
rate  of  43  per  cent. 


MENTAL    DISEASES  299 


The  deaths  during  the  fifteen  years  amounted  to  1361,  or  35  per  cent  of  the 
total  admissions. 

One  of  the  most  striking  and  instructive  facts  about  these  tables  is  this, 
that  it  was  in  the  first  two  years  after  admission  that  the  greater  number  of 
the  recoveries,  the  relapses,  and  the  deaths  took  place.  In  fact,  the  general 
results  of  the  mental  attacks  showed  themselves  in  that  time.  Seventy  per 
cent  of  the  recoveries  occurred  then,  60  per  cent  of  the  readmissions,  and  45 
per  cent  of  the  deaths. 

Unfortunately  these  tables  do  not  show  how  many  of  the  recoveries  relapsed 
into  insanity.  If  the  returns  had  shown  how  many  of  those  who  recovered 
had  relapsed,  and  how  many  times,  their  value  would  have  been  enormously 
increased.  If  the  heading  after  the  first  column  had  been  '  Relapsed  after 
Recovery,'  instead  of  '  Readmitted,'  this  result  would  have  been  obtained. 

At  the  end  of  the  fifteen  years  there  were  694  patients  of  the  3,858,  or  17-9 
per  cent,  left  uncured  in  the  institutions.  An  enormous  '  movement  of  the 
population  '  takes  place,  in  fact,  among  the  insane  as  compared  with  the 
general  population,  as  might  have  been  expected. 

In  addition  to  the  twelve  general  considerations  which  I  have  mentioned, 
there  are  many  particular  symptoms  and  indications  which  apply  in  all 
cases  of  mental  disease  in  forming  a  prognosis,  some  of  which  I  shall  describe. 
Most  of  them  are  of  importance  in  determining  this  particularly  difficult 
point. 

We  ask  in  every  case  of  mental  disease,  when  trjdng  to  solve  the  question 
of  its  chances  of  recovery,  How  did  the  disease  come  on  ?  Had  it  the  characters 
of  a  sudden  brain  explosion,  a  cloud  coming  into  a  clear  sky,  or  was  it  a  gradual 
evolution  of  mental  symptoms  beginning  with  slight  psychical  changes  and 
evolving  gradually  from  these  into  a  more  acute  and  marked  disease  ?  In 
making  inquiries  to  determine  this  important  point,  we  have  to  go  into  the 
normal  psychology  and  mental  habit  of  the  man  or  woman.  For  instance, 
we  have  to  inquire  into  the  ordinary  strength  and  the  indications  of  the  social 
instinct.  This  differs  widely  in  different  individuals  ;  but  if  we  find  that  the 
patient  became,  at  a  certain  period,  considerably  anterior  to  the  mental  attack, 
less  inclined  to  mix  with  his  fellows  in  social  intercourse,  to  be  more  self-con- 
tained, more  reticent,  more  secluded  in  his  habits,  and  that  this  gradually 
went  on  to  an  active  dislike  of  social  intercourse,  this  becoming  a  real  pain 
to  the  man  ;  if  this  went  on  further  to  a  morbid  suspicion  of  others,  a  misinter- 
pretation of  their  conduct  in  regard  to  him,  passing  into  organized  and  fixed 
insane  delusion,  leading  perhaps  to  assaults  or  homicidal  attacks  on  others — 
this  whole  sequence  of  changes  in  the  social  instinct,  if  it  took  years  to  accom- 
plish, would  lead  to  an  extremely  bad  prognosis  of  the  case,  while  if  somewhat 
the  same  symptoms  were  rapid  in  their  course  and  sequence,  say  within  a  few 
months  from  their  beginning  to  their  full  mental  development,  they  might 
not  mean  anything  like  so  grave  an  outlook  for  recovery. 

Taking  another  form,  of  mental  disease,  namely,  that  characterized  chietl>- 
by  maniacal  excitement  with  emotional  elevation,  the  outlook  in  such  a  case 
differs  greatly  according  to  the  innate  and  original  qualities  of  the  brain  that 
suffers  from  it.  If  we  have  a  case,  let  us  say,  with  a  bad  mental  or  neurotic 
heredity,  where  during  childhood  there  have  been  convulsions,  night  terrors, 
or  other  such  signs  of  brain  instability,  and  if  we  have,  during  the  developmental 
period  of  the  brain,  tendencies  to  delirium  or  even  short  attacks  of  maniacal 
or  depressed  conditions  or  periods  of  lethargy  and  stupidity,  the  prognosis 
even  in  such  a  case  need  not  be  unfavourable,  at  all  events  until  after  twenty- 
five  or  thirty  years  of  age. 


300  INDEX     OF     PROGNOSIS 

The  various  epochs  of  life  also,  and  their  effects  on  the  mental  condition  of 
men  and  women,  cannot  be  left  out  of  account  in  the  prognosis  of  any  of  the 
diseases  to  which  they  are  specially  subject,  but  especially  if  those  diseases  are 
mental  in  character.  Each  epoch  of  life  has  its  distinctive  physiological  and 
psychological  characteristics.  The  prevailing  dynamical  and  trophic  activities 
are  different  at  different  times  of  life.  The  child  period,  when  growth  in  bulk 
is  the  characteristic,  the  onset  of  sex,  child-bearing,  the  decadence  of  power 
which  marks  the  climacteric  and  old  age,  have  all  to  be  taken  into  consideration 
in  prognosis.  In  almost  any  case  of  insanity  we  cannot  dissociate  the  normal 
from  the  abnormal  psychology — one  influences  the  other.  The  insanity  is 
often  an  evolution  of  the  natural  temperament.  The  same  symptoms  occurring 
at  twenty-five  and  at  seventy  may  mean  a  quite  different  prognosis  in  the  two 
cases. 

The  time  element  in  all  forms  of  mental  disease  is  of  the  greatest  importance ; 
in  fact,  in  many  cases  this  determines  the  prognosis.  It  may  be  laid  down  as 
an  almost  universal  axioni  that  the  chances  of  recovery  diminish  after  the  first 
year  in  the  ratio  of  the  duration  of  the  attack,  except  where  the  epochs  of  life 
of  which  I  have  been  speaking  come  in.  We  never  give  up  hope  of  recovery 
in  such  cases  until  the  particular  epoch  during  which  the  attack  has  begun  is 
passed.  Different  mental  symptoms  also  afiect  the  time  limit  differently. 
For  instance,  I  was  in  the  habit  of  laying  down  to  my  students  this  dictum  : 
"  Never  give  up  hope  in  the  case  of  melancholia  while  the  depression  of  mind 
lasts."  It  is  different  with  conditions  of  exaltation.  If  they  persist  for  over 
a  year  or  two,  and  take  on  the  signs  of  chronic  mania,  the  prognosis  is  bad  ; 
if  symptoms  of  general  enfeeblement  of  mind  come  on  and  last,  say,  for  a  year, 
the  prognosis  is  almost  hopeless.  The  same  rule  applies  to  conditions  where 
we  have  regular  periodic  recurrences  of  the  mental  symptoms.  If  such  persist 
for  over  a  year  or  two  they  certainly  make  the  prognosis  bad.  The  typical 
instance  oi  a  recurring  and  alternating  insanity  is  folie  circulaire,  and  that  is 
now  regarded  as  mostly  incurable.  There  are  certain  gross  diseases  of  the  brain, 
such  as  certain  forms  of  apoplexy  and  paralysis,  wliich  on  their  first  onset  are 
apt  to  be  accompanied  by  mental  symptoms  ;  some  of  those  are  recovered 
from ;  at  all  events,  the  patients  partially  improve  in  mind,  in  such  a  way  that 
they  can  no  longer  be  regarded  as  technically  insane  ;  but  if  such  mental 
symptoms  persist  more  than,  let  us  say,  six  months,  the  prognosis  is  unfavour- 
able. The  same  rule  applies  to  many  of  the  cases  of  insanity  caused  by  alcohol, 
opium,  and  other  toxins.  If  the  mind  is  disordered  as  the  result  of  an  acute 
toxin  such  as  influenza,  we  expect  it  to  be  very  short  in  duration. 

Acuteness  of  symptoms  is  very  apt  to  be  considered  by  relations  to  be  a  bad 
sign  in  regard  to  the  prospects  of  recovery.  That  is  not  so.  I  alwaj'-s  like  an 
acute  case  of  any  kind  where  organic  brain  disease  does  not  exist,  and  tell  the 
relations  that  it  is  one  of  the  best  signs  that  the  case  will  recover  quickly  and 
perfectly.  For  instance,  one  of  the  acutest  of  all  forms  of  insanity  is  that  caused 
by  child-birth,  and  yet  none  recover  so  certainly,  quickly,  and  completely. 
There  is,  of  course, 'a  greater  risk  of  death  in  the  acute  cases,  and  this  should 
always  be  explained  to  relations.  Eight  per  cent  of  all  cases  of  acute  mania 
die  of  the  disease,  and  the  mortality  in  puerperal  insanity  is  even  greater. 

Facial  Expression  in  Prognosis.^ — The  mental  expression  of  the  face  and  eyes 
in  most  cases  of  mental  disease  should  be  carefully  observed.  It  is  changed 
for  the  worse,  and  in  some  of  its  more  acute  varieties  it  is  so  changed  that  the 
man  is  almost  unrecognizable  by  his  friends.  The  only  exceptions  to  this  are 
in  the  case  of  persons  who  are,  by  temperament  and  natural  disposition,  slow, 
stupid,  and  lethargic.     I  have  seen  many  such  who,  during  a  mild  attack  of 


MENTAL     DISEASES  301 


mental  exaltation,  were  brighter  and  better  looking  than  ever  they  were  in 
their  lives.  There  are  only  two  facial  disturbances  of  a  decided  kind  that  1 
think  are  unfavourable  in  prognosis.  Those  are  the  heavy  wiped-out  expression 
of  the  face  and  eyes  in  the  young  man,  and  particularly  in  the  3'oung  woman, 
who,  towards  the  end  of  an  attack  of  adolescent  insanity,  has  passed,  or  is 
passing,  into  dementia.  The  other  is  the  cunning,  suspicious  expression  of 
the  patient  who  suffers  from  paranoia  of  the  persecutory  type.  All  the  ordinary 
disturbances  of  expression  but  these,  however  extreme  they  are,  may  be 
recovered  from,  and  the  patient  resume  his  normal  appearance. 

The  muscular  expression  of  the  emotions  is  not  sufficiently  realized  in  mental 
practice.  There  are  fifty  mind  and  eye  muscles,  not  including  all  those  of  speech, 
the  action  of  which  make  all  the  difference  in  their  mental  expressions  between 
one  man  and  another.  They  are  extremely  small  in  size,  but  they  are  innervated 
to  an  enormous  degree.  Their  motor  ner^^es  together  are  as  bulky  as  those  of 
the  arm  muscles,  wliich  weigh  a  hundred  times  as  much.  It  is  only  when  those 
mind-muscles  of  expression  and  eye  show  a  certain  disturbed  mode  of  action 
which  lasts  for  a  long  time,  that  such  changes  indicate  a  bad  prognosis. 
Commonly  they  change  quicklj^  from  good  to  bad  expressions,  and  vice  versa. 

Causation  and  Prognosis. — The  cause  or  causes  of  a  mental  attack  have  often 
much  relation  to  the  prognosis  in  the  case.  The  causes  which  may  determine  an 
attack  of  mental  disease  are  almost  innumerable,  and  I  cannot  in  this  article 
refer  to  all  of  them.  Commonly,  when  the  history  of  a  case  is  gone  into,  one 
finds  that  there  existed  more  than  one  cause  of  the  attack.  There  is  often  a 
predisposing,  an  exciting,  and  a  proximate  cause.  For  instance,  a  man  ma}- 
have  a  bad  brain  heredity  as  a  predisposing  cause,  may  have  taken  alcohol 
to  excess  as  an  exciting  cause,  and  had  a  fall  on  the  head  as  the  proximate 
cause  of  his  attack.  Then  in  some  cases  there  are  even  more  than  one 
exciting  cause.  I  shall  further  on  refer  to  heredity,  which  is  the  chief  and 
most  common  of  all  the  predisposing  causes.  There  is  a  strong  natural 
craving  to  find  a  cause  for  such  a  tragic  event  in  life  as  an  attack  of 
mental  disease.  Relatives  will  press  their  doctor  on  this  point  very  unduly, 
and  if  a  cause  can  be  assigned  there  is  very  often  a  sense  of  relief  and  a  more 
hopeful  feeling  as  to  the  chances  of  recovery.  I  often  hear  this  remark  :  "I 
feel  happier  now  I  know  the  cause  of  the  illness."  The  relations  of  our  patients 
are  exceedingly  apt  to  assign  causes  which  by  no  possibility  can  be  the  real 
ones.  The  causes  which  a  mother  will  assign  for  idiocy  in  her  child  may  be 
almost  grotesque  in  their  unreality.  To  account  for  a  mental  attack,  relations 
nearly  always  seek  a  mental  or  a  moral  cause.  In  reality  we  know  that  only 
about  one-fourth  of  all  the  cases  of  mental  disease  are  due  to  mental  causes, 
the  other  three-fourths  resulting  from  bodily  causes.  Looking  over  the  tables 
of  the  causes  of  the  diseases  which  are  usually  attached  to  the  annual  reports 
of  our  large  mental  hospitals  does  not  always  help  us  ver^'-  much.  iVIany  of 
the  terms  are  too  general  to  be  of  any  scientific  or  prognostic  use. 

It  may  be  assumed  generally  that  a  cause,  or  what  may  be  reasonably  assumed 
to  be  a  cause,  of  a  mental  attack,  will  be  less  likel}^  to  produce  an  incurable  brain 
malady  if  it  is  removable.  Taking  such  causes  as  toxins  affecting  the  higher 
brain  cells,  most  of  them  either  exhaust  their  action  on  the  brain  quickly,  or  an 
immunity  is  set  up,  or  they  can  be  more  or  less  counteracted  by  suitable  treat- 
ment. I  take  as  examples,  cases  of  mental  disease  caused  by  or  following  the 
action  of  the  influenza  poison  or  sj'philis  or  alcohol.  These  together  cover  a 
very  considerable  part  of  the  era  of  mental  disturbances.  Then  there  are  causes 
which  are  in  their  nature  transitory,  such  as  child-birth,  many  forms  of  bodily 
disease   and   exhaustion,    surgical    operations,   etc.     In   regard   to   the   mental 


INDEX     OF     PROGNOSIS 


and  moral  causes  of  psychical  disease,  many  of  them  soon  exhaust  their  dele- 
terious action,  or  can  be  counteracted  by  changes  of  circumstances  and  environ- 
ment ;  of  such  are  overwork,  some  forms  of  domestic  worries,  love  affairs,  and 
mental  shocks.  On  the  other  hand,  there  are  causes  that  are  almost  necessarily 
irremovable,  which  therefore  lead  to  a  bad  prognosis,  such  things,  for  instance,  as 
traumatic  injuries  to  the  head,  senility,  alcoholic  excess  so  long-continued  that 
the  organic  structure  of  the  cells  or  vessels  are  changed,  gross  cerebral  disease, 
epilepsy,  etc.  The  mental  symptoms  may  not  be  the  main  or  original  element 
in  the  case.  They  may  be  so  secondary  to  bodily  disease  that  the  prognosis 
may  depend  almost  entirely  on  the  nature  of  such  bodily  causes.  I  would 
take  as  an  example  cases  dependent  on  heart  or  uterine  disease,  on  cancer, 
on  diabetes,  or  on  pernicious  anaemia.  Finally,  the  innate  vulnerability  and 
power  of  resistance  of  brain  have  to  be  taken  into  account  when  estimating 
prognosis  in  regard  to  causation.  One  brain  raay  be  upset  by  a  cause  which 
in  another  would  produce  no  serious  result  at  all.  The  unstable  and  vulnerable 
brain  mav,  however,  throw  off  bad  effects  far  more  readily  and  quickly  than 
the  more  stable  brain.  Our  modern  methods  of  examination  have  enabled  us 
to  discover  changes  in  the  spinal  fluid  and  blood  and  micro-organisms  which  are 
very  valuable  in  regard  to  the  prognosis  in  some  cases. 

Response  to  Treatment. — Every  medical  man  is  influenced  in  his  prognosis 
by  the  effects  of  his  treatment,  using  treatment  in  its  larger  sense  of  environment, 
nursing,  and  diet,  and  not  confining  it  to  drug  treatment  alone.  If  a  patient,  for 
instance,  falls  into  depression  of  mind  on  account  of  unfavourable  or  local 
•circumstances,  and  when  he  is  sent  away  for  a  change  at  once  begins  to  brighten 
and  have  his  attention  taken  up  with  his  new  surroundings,  it  is  necessarily  a 
favourable  sign  in  prognosis  ;  or  if,  in  any  case,  we  have  to  do  with  thinness  and 
general  want  of  nutrition  in  a  patient  suffering  from  any  form  of  mental  disturb- 
ance, and  our  efforts  to  increase  his  weight  by  diet  or  drugs  or  change  of  air  are 
successful,  we  think  better  of  his  chances  of  recover}^  I  have  sometimes 
watched  with  so  much  anxiety  the  putting  on  of  the  first  pound  or  two  of 
weight  in  a  patient  whom  I  was  treating,  that  my  whole  outlook  became  more 
optimistic  when  that  took  place. 

Insomnia,  so  very  common  a  symptoni  in  most  cases  of  mental  disease,  both 
as  preliminary  to  and  during  the  disease,  gives  us  the  greatest  anxiety  in  regard 
to  the  effects  of  treatment.  It  is  so  very  intractable,  in  some  cases,  that  we 
feel  the  patient  cannot  recover  his  mental  balance  until  it  is  subdued.  Nothing 
is  more  exhaustive  to  the  higher  mental  functions  of  the  brain  than  prolonged 
insomnia.  If  by  drugs,  by  change  of  air,  by  medical  treatment,  we  find  that 
the  normal  periodicity  in  the  occurrence  of  sleep  is  restored,  we  feel  that  the 
patient  will  almost  certainly  recover  in  due  time.  Volumes  have  been  written 
as  to  what  sleep  is,  and  as  to  the  best  methods  of  restoring  it  when  insomnia 
is  present,  but  we  all  feel  that  as  yet  neither  of  those  problems  has  passed  into 
the  region  of  scientific  certainty.  We  do  surely  know  that  sleep  is  the  greatest 
and  most  important  of  all  the  examples  of  periodicity  in  the  physiological  and 
mental  life  of  a  human  being.  We  also  know  that  it  is  Nature's  most  important 
method  of  resting  the  higher  functions  of  the  brain  and  of  restoring  to  a  proper 
state  of  nutrition  the  brain  cells.  Everyone  who  has  thought  about  the  subject 
realizes  that  the  ph3^siological  unconsciousness  of  sleep  is  quite  as  mysterious 
as  the  occurrence  of  any  mental  disease  whatever.  Dreaming  is  the  nearest 
physiological  analogy  to  insanity.  I  believe  that  when  we  discover  the  secret 
of  sleep  it  will  lead  to  the  discovery  of  the  prevention  of  much  mental  disease. 

Mental  Hospital. — The  response,  favourable  or  otherwise,  to  the  removal 
of  a  patient  to  a  mental  hospital  undoubtedly  affects  prognosis  in  his  case. 


MENTAL    DISEASES  303 


Unfortunately,  the  ideas  of  many  of  the  pubUc  regarding  mental  hospitals, 
and  the  feelings  of  repulsion  and  distress  which  those  ideas  have  produced, 
in  some  cases  tend  to  counteract  the  good  effects  of  the  control,  discipline, 
regime,  and  medical  treatment  which  are  given  in  such  institutions.  Happil}' 
such  wrong  ideas  are  now  undergoing  a  marked  change,  and  a  great  many 
patients  are  willing  to  place  themselves  under  treatment  voluntarily  in  mental 
hospitals.  This  is  the  most  satisfactory  method  of  all  in  the  cases  where  it  is 
suitable.  Unfortunately,  the  majority  of  cases  of  mental  disease  do  not  recog- 
nize they  are  ill,  and  therefore  resent  such  treatment  as  being  unjustifiable. 
But  if  a  patient  shows  a  marked  betterment  during  his  first  month's  residence 
in  the  hospital,  it  improves  the  prognosis  in  the  case  very  much.  Before  going 
to  such  a  hospital,  the  doctor  has  commonly  to  make  the  likelihood  of  an 
improved  prognosis  if  sent  there  his  chief  argument  for  that  course  being 
adopted,  and  undoubtedly  in  the  larger  number  of  cases  such  a  prognosis  is 
justified  by  the  results.  Unfortunately,  at  present,  the  risk  of  danger  to  him- 
self or  others  is  rather  too  much  of  an  element  for  the  sending  of  patients  to 
mental  hospitals.  In  reality  the  great  reason  should  be  the  improved  chances 
of  recovery  and  the  impossibility  among  the  poor  of  securing  proper  treatment 
otherwise. 

There  are  a  certain  number  of  cases  where  the  prognosis  is  distinctly  improved 
by  removing  patients  from  mental  hospitals  to  other  environments.  This 
occurs  sometimes  in  a  too  prolonged  convalescence,  where  such  a  change  restores 
the  interests  in  life  and  stimulates  the  patients  to  a  greater  amount  of  self- 
control.  Speaking  generally,  however,  I  am  of  opinion  that  the  best  chance  of 
complete  recovery  and  of  non-recurrence  of  the  disease  is  secured  by  the  patient's 
residence  in  the  hospital  until  such  recovery  has  not  only  taken  place,  but 
may  be  said  to  be  established. 

Langer  of  Recurrence. — In  many  forms  of  ordinary  disease  the  patients 
are  liable  to  a  recurrence  at  some  time  or  other  after  recovery  has  taken  place. 
Gout,  rheumatism,  bronchitis  are  common  examples  of  this  tendency.  Mental 
disease  is  liable  to  recur  in  at  least  20  per  cent  of  those  who  have  recovered, 
and  in  many  cases  this  tendency  occurs  over  and  over  again.  There  are  a 
certain  number  of  cases  where  the  more  frequent  the  occurrence  the  greater 
the  danger  is  of  a  final  incurability,  but  this  does  not  apply  to  all  of  them.  I 
have  known  many  cases  recover  and  relapse  on  very  many  occasions,  the 
recoveries  being  good  ones  while  they  lasted,  and  the  patient  able  to  take 
his  place  in  society  and  do  his  usual  work.  The  classic  case  of  Charles  Lamb 
and  his  sister  is  an  example.  In  many  cases  that  have  this  tendency,  the 
treating  of  the  symptoms  in  time,  before  they  have  developed  into  serious  mental 
disease,  is  the  great  principle  to  be  adopted.  Cure  the  insomnia,  restore  the 
nutrition,  give  a  chance  for  brain  rest,  change  the  current  of  ideas  and  thoughts, 
remove  causes  of  irritation  or  exhaustion,  give  a  fillip  to  the  mental  life, 
are  all  modes  of  effective  treatment,  and  they  improve  prognosis  in  most  cases. 
Statistically  the  danger  of  recurrence  is  scientifically  brought  out  in  the  Scottish 
statistics  referred  to  on  page  298. 

Heredity  as  an  Element  in  Prognosis, — The  influence  of  a  bad  heredity  in 
making  any  man  or  woman  liable  to  mental  disease  has  always  been  taken 
into  account  by  those  with  experience  in  the  medical  profession.  It  was  evident, 
on  even  casual  observation,  that  some  families  were  more  liable  to  such  diseases 
than  others.  Of  recent  years  much  more  careful  clinical  and  statistical  know- 
ledge on  this  point  has  been  obtained.  The  ordinary  methods  of  scientific 
statistics,  and  those  of  biometrics,  have  been  called  in  to  attain  accuracy,  with 
much,  but  not  as  yet  complete,  success.     Dr.  Karl  Pearson  and  Dr.  Mott  arc 


304  INDEX     OF     PROGNOSIS 

the  latest  authorities  on  this  important  subject,  and  their  work  has  undoubtedly 
advanced  our  knowledge.  For  myself  I  have  much  more  faith  in  what  may 
be  called  the  clinico-statistical  methods  of  Dr.  Mott  than  those  of  the  purely 
mathematical  methods  of  Dr.  Karl  Pearson.  Two  things  I  would  especially 
impress  on  the  readers  of  this  article  in  regard  to  heredity  are  these  :  The  worst 
and  the  most  direct  heredity  need  not  imply  the  occurrence  of  mental  disease 
in  any  family,  and  the  existence  of  heredity,  even  strong  heredity,  does  not 
necessarily  imply  incurability  in  any  case.  We  are  nowadays  continually 
asked  about  the  liabilities  to  mental  and  nervous  disease  in  certain  families 
where  there  are  intentions  of  marriage,  proposals  of  insurance,  uncertainties 
about  taking  to  certain  occupations  or  professions,  and  thoughts  of  going  to 
live  in  certain  climates.  This  reading  of  the  horoscope  of  human  beings  is, 
or  ought  to  be,  a  department  of  prognosis,  and  as  our  scientific  knowledge 
increases  it  will  become  an  extremely  important  part.  It  is  already  affecting 
the  great  science  of  education  in  a  marked  degree.  It  is  affecting  certain  acts 
of  the  legislature  that  relate  to  social  questions.  It  may  be  said  to  be  affecting 
men's  views  of  ethics  and  of  human  conduct.  It  has  also  a  relation  to  literature, 
especially  in  history  and  biography.  Long  ago,  in  reading  Carlyle's  biography 
of  Frederick  the  Great,  one  was  impressed  by  the  fact  that  that  shrewd  writer 
devoted  his  first  volume  entirely  to  Frederick's  ancestry  and  relations,  their 
history  and  characters.  He  did  not  use  the  word  heredity,  but  that  volume 
is  a  treatise  on  the  subject  notwithstanding. 

The  keynote  of  the  new  science  of  eugenics  depends  on  heredity,  and  as  a 
result  of  the  perfecting  of  that  science,  prognosis,  in  a  large  sense,  will  be  made 
far  more  accurate.  It  may  be  described  indeed  as  the  most  comprehensive 
field  of  prognosis  at  present  in  existence,  for  all  its  aims  consist  of  looking  to 
the  future  in  human  life. 

In  the  prognosis  of  mental  diseases  it  is  to  be  remembered  that  it  is  not  the 
special  mental  defect  or  disturbance  that  is  inherited,  but  a  general  defect  of 
brain  nutrition,  or  an  instability  of  action  in  the  higher  brain  cells,  or  a 
deficiency  of  resistance  against  toxins  or  against  mentally  upsetting  causes. 
Heredity  may  consist,  and  in  many  cases  of  mental  disease  at  the  adolescent 
period  does  consist,  of  a  want  of  ability  to  adjust  the  action  of  the  brain  cells 
— the  vehicles  of  mind — to  the  more  complicated  and  evolved  life  of  civilized 
man  as  compared  with  that  of  primitive  ancestors.  Dr.  Mercier  says  :  "  The 
stability  or  instability  of  a  person's  highest  nervous  arrangements  depends 
primarily  and  chiefly  on  inheritance."  Without  evil  mental  heredity  there 
would  be  very  little  unsoundness  of  mind  in  the  world.  It  is  one  of  the  chief 
problems  of  psychiatry.  In  considering  the  heredity  of  any  case  of  mental 
disease  with  a  view  to  prognosis,  we  must  inevitably  consider  whether  the 
defects  in  fathers  or  mothers,  if  any  such  exist,  were  personally  acquired,  or 
derived  from  an  ancestry  further  back.  To  a  large  extent  the  belief  as  to  the 
non-transmissibility  of  any  personally-acquired  characters  held  the  field  till 
lately,  but  a  newer  generation  of  scientists  are  of  opinion  that,  in  certain  circum- 
stances, they  may  be  transmitted.  Professor  Cossar  Ewart,  a  great  authority, 
as  the  result  of  practical  experiments,  says  that  "  the  germ  cells  are  liable  to 
be  influenced  by  fever  and  other  forms  of  disease  that,  for  the  time  being, 
diminish  the  vitality  of  the  parents,"  and  we  have  also  the  great  authority  of 
Darwin,  Maudsley,  and  Hertwig  for  holding  the  same  views. 

If  we  find,  in  addition  to  a  bad  hereditary  history,  that  there  are  bodily  abnor- 
malities in  our  patients,  which  we  now  call  '  stigmata  of  degeneration,'  the 
prognosis  is  considerably  worsened.  In  inquiring  into  the  heredity  of  any 
case,  we  must  take  into  account  not  only  mental  but  also  neurological  facts, 


MENTAL     DISEASES  305 


such  as  epilepsy,  malformations,  convulsions,  chorea,  asthma,  stammering, 
hysteria,  and  many  other  such  allied  diseases.  One  law  of  mental  heredity 
laid  down  by  me  long  ago,  and  now  fully  confirmed  on  larger  statistics  by  Dr. 
Mott,  is  that  any  mental  defect  in  ancestry  is  liable  to  occur  at  an  earlier  age 
in  posterity  than  the  age  in  which  it  occurred  in  parents.  It  is  also  a  fact  that 
the  maternal  heredity  towards  mental  and  other  nervous  diseases  is  stronger 
than  the  paternal,  and  the  mental  defects  tend  to  cross  the  sexes  from  mother 
to  son,  etc.  It  is  also  certain  that  while  a  strong  heredity  does  not  imply 
incurability  to  any  one  attack,  yet  it  does  produce  a  greater  tendency  to 
recurrence  of  the  disease ;  and,  finally,  as  a  most  important  consideration  in 
prognosis,  few  of  us  now  doubt  that  in  a  vast  number  of  cases  a  bad  heredity 
can  be  counteracted,  in  some  degree  at  least,  or  modified,  by  favourable  environ- 
ments and  modes  of  life. 

The  Age  of  the  Patients. — Youth,  in  mental  diseases,  as  in  all  others,  is  a 
favourable  element  in  prognosis,  ceteris  paribus.  Some  mental  diseases,  such 
as  senile  dementia,  are  incurable  simply  because  the  patient  is  old.  Some 
others  are  apt  to  recover  because  they  occur  in  the  developmental  period  of  life. 
Nature  always  tends  towards  nealth  if  she  has  a  fair  chance.  Some  diseases, 
such  as  choreic  insanity,  will  almost  necessarily  recover  because  they  are 
developmental  in  their  character. 

Completeness  of  the  Recovery. — The  prognosis  in  all  our  cases  largely  depends 
on  whether  the  attack  has  been  absolutely  and  completely  recovered  from. 
In  mental  disease,  unfortunately,  there  are  apt  to  be  left  certain  of  the  slighter 
peculiarities  of  character  and  conduct.  These,  if  they  persist  too  long,  are 
liable  to  become  brain  habits  difficult  to  get  rid  of. 

Temperament. — The  original  temperament  of  the  patient,  to  a  certain  extent, 
determines  the  prognosis  of  his  attack  if  he  falls  into  certain  forms  of  mental 
disease.  Melancholia  in  a  markedly  melancholic  temperament  is  not  so  curable 
as  in  a  sanguine  temperament.  Mania  is  not  so  curable  in  the  case  of  aa 
excitable,  boisterous,  nervous  temperament  as  in  a  man  with  an  ordinary- 
average  working  brain. 

Conditions    of    Simple    Mental     Depression    and    Elevation — 
Manic-depressive  Insanity. 

"Whatever  classification  of  mental  disease  may  ultimately  be  adopted,  I  am 
satisfied  that  there  are  certain  morbid  conditions  which  for  the  general  practitioner 
and  the  relatives  of  patients  it  will  always  be  necessary  to  reckon  with  and 
to  treat  as  distinct  forms  of  disease.  The  chief  of  these  are  states  of  mental 
depression  and  mental  elevation  with  diminished  self-control.  From  the 
earliest  times  in  the  history  of  medicine  these  have  been  recognized.  The  terms 
melancholia  and  mania  have  become  a  part,  not  only  of  medical  books,  but  of 
popular  language  and  of  literature.  The  conditions  I  am  to  describe  are  those 
which  are  apt  to  come  under  the  notice  of  the  medical  practitioner  in  his  ordinary 
work,  commonly  before  a  specialist  is  called  in.  It  is  essential,  therefore,  that 
right  conceptions  regarding  their  nature,  causes,  risks,  prognosis,  and  treatment 
should  be  held  by  every  doctor.  Especially  when  they  exist  in  a  minor  degree 
and  constitute  what  we  now  call  the  '  borderland,'  it  is  important  that  they 
should  be  subjected  to  the  right  kind  of  treatment,  and  that  their  prognosis 
should  be  well  considered.  I  believe  if  proper  treatment  is  carried  out  they 
may  be  arrested  in  many  cases,  and  recoveries  may  be  brought  about  before 
they  reach  their  more  serious  stages,  the  necessity  of  being  placed  in  mental 
hospitals  thus  being  avoided.     I  shall   refer  both  to  my  experience  in  treating 

20 


3o6  INDEX     OF     PROGNOSIS 

them  in  a  mental  hospital,  and  also  as  a  consulting  physician  where  I  had  to 
advise  as  to  their  treatment  in  private  houses,  in  rooms,  or  in  nursing  homes. 

Among  the  practical  classifications  adopted  in  most  mental  hospitals,  conditions 
of  depression  are  usually  assorted  into  the  varieties  of  simple,  hypochondriacal^ 
delusional,  suicidal,  resistive,  excited,  and  stuperose.  The  cases  of  simple 
melancholia  are  those  which  the  general  practitioner  of  medicine  sees  most  of 
from  start  to  finish.  It  is  the  most  rational  of  all  the  insanities.  The  patients 
themselves  and  their  relations  usually  object  to  its  being  called  mental  disease 
at  all.  They  talk  of  it  as  '  nervous  depression,'  '  melancholy,'  '  low  spirits,' 
being  '  out  of  sorts,'  and  being  '  run  down.'  I  am  not  of  course  alluding 
to  the  cases  of  mere  physiological  depression  of  mind  from  natural  emotional 
causes.  Mere  physiological  melancholy  might  be  defined  as  a  sense  of  ill-being 
and  a  feeling  of  mental  pain,  with  no  real  perversion  of  the  normal  reasoning 
power,  no  morbid  loss  of  self-control,  no  impulses  towards  suicide,  the  power  of 
working  not  being  abolished,  and  the  ordinary  interests  of  life  only  lessened, 
not  destroyed.  The  simple  melancholia,  whose  prognosis  I  am  to  treat  of, 
is  a  really  pathological  condition  of  the  brain  cortex  accompanied  by  mental 
pain,  emotional  depression,  a  sense  of  ill-being  more  intense  than  melancholy, 
with  some  loss  of  self-control  or  volitional  power,  perhaps  a  tendency  to  delusion 
of  a  depressed  character,  the  power  of  doing  ordinary  work  being  greatly 
diminished  or  abolished,  the  interests  of  life  interfered  with,  and  with  discoverable 
bodily  symptoms  in  nine  cases  out  of  ten. 

In  the  examination  of  such  cases  the  patient  himself  is  of  the  greatest  assist- 
ance, because  he  knows  he  is  ill,  sometimes  perhaps  exaggerating  his  symptoms. 
The  patient's  '  objective  consciousness  '  is  morbidly  acute,  while  his  '  sub- 
jective consciousness  '  is  exaggerated.  Such  a  patient  is  usually  run-down 
in  body,  and  has  had  some  physical  or  mental  antecedents  which  have  been 
the  cause  of  his  trouble.  There  is  usually  more  or  less  insomnia.  The  patient 
has  either  a  jaded  or  a  more  or  less  irritable  feeling,  his  work  instead  of  being 
a  pleasure  is  a  conscious  toil,  he  has  a  sense  of  ill-being,  the  opposite  of  that 
normal  sense  of  well-being  which  is  to  all  mankind  the  best  proof  of  health. 
The  nutrition  of  the  body  is  lowered ;  commonly  there  is  want  of  appetite  and 
constipation.  The  depression  is  nearly  always  worst  in  the  morning.  This 
is  a  fact  well  worth  keeping  in  mind  in  treatment  and  prognosis,  for  certain 
measures  can  often  be  taken  to  rouse  the  brain  from  this  morning  depression 
into  somewhat  normal  action.  It  is  not  often  kept  in  mind  that  sleep,  in  addition 
to  the  marvellous  condition  of  unconsciousness  which  accompanies  it,  does 
so  alter  the  working  of  the  higher  cortical  cells  or  their  capillary  circulation 
that  they  do  not  resume  work  for  a  little  time  after  sleep  is  past.  In  a  minor 
degree  this  is  a  common  enough  thing  in  people  who  are  far  from  being  mentally 
diseased. 

Although  the  definition  of  this  simple  state  of  melancholia  cannot  be  exact, 
it  having  no  definite  boundary  lines  from  either  sanity  on  the  one  hand,  or 
the  more  severe  varieties  of  the  disease  on  the  other,  we  can  for  practical 
purposes  ask  :  What  are  its  chances  of  recovery  and  its  general  prognosis,  its 
liability  to  relapse,  and  the  fear,  if  any,  of  a  fatal  result }  The  general  pro- 
gnosis is  unquestionably  a  favourable  one ;  but  in  order  to  give  a  statistical 
basis  for  that  opinion  I  shall  take  my  experience  during  the  last  ten  years  I  was 
Physician-Superintendent  of  the  Royal  Edinburgh  Mental  Hospital,  from  1897 
till  1908.  I  must  explain  that  while  this  condition  of  simple  melancholia  may 
usually  be  quite  well  treated  at  home  if  the  patient's  finances  admit  of  it, 
that  is  expensive  if  practicable.  For  the  poor  and  the  '  lower  middle  class,' 
most  of  the  cases  have   to  be  sent  to  mental   hospitals,  on  account  of  there 


MENTAL     DISEASES  307 

being  no  means  of  proper  treatment,  and  of  the  patients  not  being  able 
to  earn  their  own  livelihood.  In  the  ten  years  I  had  under  my  care 
altogether  4319  cases  of  mental  disease.  Of  those,  414,  or  15  per  cent,  say  one- 
seventh,  were  cases  of  simple  melancholia.  It  is  therefore  one  of  the  most 
frequent  of  all  the  varieties  of  mental  disorder.  Of  the  414  cases,  225  recovered, 
or  54'3  per  cent.  Considering  that  two-thirds  of  the  remainder  were  discharged 
(technically  relieved),  and  one-third  of  those  probably  completed  their  recovery 
after  their  return  home,  I  think  it  would  be  a  reasonably  correct  estimate  to 
say  that  70  per  cent  is  the  chance  of  making  a  recovery  in  this  class.  The  rest 
of  the  cases,  the  30  per  cent,  passed  either  into  the  more  severe  varieties  of 
melancholia  or  into  dementia,  while  a  few  died.  Less  than  i  per  cent  died, 
and  that  was  through  the  exhaustion  of  acuter  symptoms  coming  on,  or 
through  their  becoming  so  low  in  nutrition  that  intercurrent  diseases,  such  as 
phthisis,  pneumonia,  etc.,  carried  them  off.  I  may  say  very  few  of  those  cases 
of  simple  melancholia  were  really  suicidal.  All  the  suicidal  cases,  or  rather 
the  worst  of  them,  I  included  under  the  separate  heading  of  suicidal  melancholia, 
but  no  doubt  the  general  idea  that  life  is  not  worth  having,  and  some  little 
risk  of  suicide,  was  present  in  some  of  them. 

It  is  interesting  to  compare  all  the  eases  of  melancholia,  the  simple  and  the 
more  severe,  as  to  prognosis,  with  the  special  group  that  I  have  called  simple. 
There  were  altogether  1465  cases  grouped  under  melancholia,  including  the 
simple  variety,  and  of  the  total  number  43'7  per  cent  recovered.  Adding  the 
proportion  of  the  relieved,  which  is  not  so  great  as  in  the  siniple  variety  alone, 
the  general  prognosis  as  to  recovery  in  conditions  of  depression  of  mind  suffici- 
ently severe  to  be  sent  to  institutions  may  be  put  down  at  about  55  per  cent. 

Duration. — Patients  themselves  and  their  relations  are  commonly  very 
urgent,  not  only  as  to  whether  recovery  will  take  place,  but  how  long  the 
symptoms  will  last.  This  is  the  most  difficult  part  of  the  prognosis  in  all 
mental  cases.  The  grounds  for  giving  a  time  limit  are  always  somewhat  un- 
certain ;    the  data  are  commonly  insufficient. 

Simple  melancholia,  however  mild  in  its  symptoms,  is  not  one  of  the  mental 
disorders  that  we  expect  to  pass  off  suddenly ;  its  recovery  is  usually  gradual, 
and  we  cannot  count  on  a  case  recovering  speedily  because  its  symptoms  are 
specially  mild.  There  are  some  cases  of  simple  melancholia  that  recover  within 
three  months,  but  taking  them  all,  their  duration  is  over  that  time.  We  may, 
however,  reasonably  expect  a  recovery  in  this  disease  within  six  months  from 
its  beginning.  Only  about  10  per  cent  persist  for  over  a  year  before  recovery. 
Certainly  three-fourths  of  the  recoveries  take  place  in  that  time.  Its  symptoms 
are  so  mild  in  many  cases  that  it  is  difficult  to  say  when  a  complete  recovery 
has  taken  place.  In  the  above  estimate  of  recovery  I  assume  that  the  patient 
has  been  for  a  month  free  from  any  symptoms  of  mental  depression  before  the 
statistics  are  drawn  up.  Simple  melancholia  is  one  of  the  diseases  from  which 
a  complete  recovery  is  not  only  possible,  but  is  likely  to  occur. 

Indications  of  Improvetnent. — In  nearly  all  cases  of  melancholia  the  symptoms 
are  worst  in  the  morning  and  forenoon,  while  the  patients  improve  towards 
afternoon  and  evening.  It  may  be  held  to  be  a  good  sign  when  the  evening 
remissions  are  complete,  the  patient  feeling  quite  well ;  and  if  along  with  this 
the  morning  exacerbation  is  not  so  severe  as  at  the  beginning  of  the  disease, 
it  is  also  a  good  indication.  In  most  cases  of  melancholia  the  patients  are  not 
able  to  follow  their  usual  occupation  or  any  occupation  in  a  continuous  and 
efficient  way,  or  if  they  do  some  work  it  is  done  with  little  interest  and  somewhat 
forced.  It  is  always  a  good  sign  when  a  patient  is  able  to  resume  any  kind  of 
occupation  for  any  part  of  the  day.     We  often  treat  such  patients  by  keeping 


3o8  INDEX     OF     PROGNOSIS 

them  in  bed  at  first.  If  that  has  a  good  effect,  it  is  a  good  sign  as 
making  for  recovery.  I  constantly  find,  in  the  case  of  women  who  have 
been  accustomed  to  that  form  of  employment,  that  simple  knitting  is  a 
most  excellent  occupation,  being  simple,  not  requiring  any  great  amount  of 
attention,  and  implying  some  muscular  effort.  When  the  patients  become 
more  inclined  for  active  outdoor  exercise  it  is  always  a  good  sign.  If  the  stimu- 
lating nerve  tonics,  which  we  usually  employ  as  a  remedy  in  such  cases,  mani- 
festly have  an  effect  for  good  on  the  brain  action,  it  is  a  good  sign.  Above 
all,  if  the  patients  gain  weight  steadily,  and  if  their  appetites  and  digestion 
improve,  it  is  a  favourable  sign.  Constipation  being  a  frequent  accompaniment 
of  melancholia,  it  always  means  a  general  betterment  when  the  bowels  resume 
their  normal  action.  If  the  skin  becomes  softer  and  the  perspiration  more 
normal,  it  may  be  looked  upon  as  favourable  in  prognosis.  If  the  patients 
have  had,  as  most  of  them  have,  an  idea  that  they  will  not  and  cannot  get 
better,  and  cease  to  be  obsessed  in  this  way,  and  begin  to  believe  that  there  is 
a  hope  of  their  recovery,  it  is  a  sure  sign  that  they  are  on  the  way  to  recovery. 
It  is  one  of  the  great  means  of  mental  treatment  to  assure  every  melancholic 
patient  that  he  will  certainly  get  better,  and  I  am  in  the  habit  of  telling  my 
nurses  to  reiterate  this  to  every  such  patient  at  least  a  dozen  times  a  day.  This 
is  a  legitimate  '  mind-cure.'  If  the  patient  has  been  restless  and  that  symptom 
diminishes,  it  is  a  good  sign.  If  there  had  been  any  tendency  to  delusion  and 
that  diminishes  in  force,  it  is  also  a  good  indication  that  recovery  is  soon  going 
to  take  place.  There  is  a  symptom  which  I  have  often  noticed  in  cases  of 
melancholia.  The  patients,  during  the  earlier  part  of  the  disease,  are  often 
abnormally  deficient  in  will-power  and  are  too  calm  in  temper.  If  a  stage  of 
irritability  comes  on  I  look  on  it  as  a  good  sign.  I  had  one  patient  whom  I 
was  always  glad  to  hear  using  strong  language.  I  knew  then  that  he  was  going 
to  recover.  The  conscious  sense  of  organic  well-being  is  the  last  to  come,  that 
being  the  best  subjective  sign  of  health.  A  symptom  worthy  of  observation 
is  the  return  of  minor  neuroses  or  ailments  to  which  the  patient  may  have  been 
subject,  e.g.,  headaches,  asthma,  skin  troubles,  etc.  When  these  are  seen  it  is 
a  good  sign  of  approaching  mental  recovery.  If  a  patient  has  had  a  quick 
and  irritable  pulse,  and  that  disappears,  it  is  a  good  sign. 

Unfavourable  Indications. — The  following  symptoms  are  those  which  make 
the  prognosis  more  uncertain  or  entirely  unfavourable.  If  the  onset  of  the 
depression  has  been  exceedingly  slow  and  gradual,  and  its  symptoms  more  and 
more  serious  in  their  development,  if  there  is  a  gradual  decay  of  bodily  vigour, 
like  a  premature  old  age,  and  a  persistent  loss  of  nutritive  tone  and  bodily 
weight  that  will  not  jdeld  to  diet  and  treatment,  it  is  a  bad  sign.  If  hallucina- 
tions of  hearing  come  on,  we  do  not  like  it.  If  there  are  convulsive  attacks  or 
slight  shocks  of  paralysis,  we  know  that  organic  disease  of  the  brain  cells  has 
set  in  and  that  there  is  little  hope  of  mental  recovery,  but  I  have  seen  many 
exceptions  to  this.  If  the  patient  in  facial  expression  takes  on  a  prematurely 
old  appearance  it  is  not  a  good  sign,  or  if  the  emotional  depression  of  face  and 
eye  gets  permanently  fixed  without  any  smile,  or  if  muscular  expressions  of 
mental  pain  come  on,  such  as  wringing  of  the  hands,  groaning,  etc.,  or  if  a 
suicidal  tendency  develops  and  gets  extremely  intense,  those  are  bad  signs. 
If  there  are  proofs  of  marked  arteriosclerosis  or  other  vascular  degenerations, 
they  add  much  gravity  to  the  prognosis.  If  there  is  seen  a  general  weakening 
of  the  mental  power,  the  memory,  power  of  attention,  and  interest  in  life,  the 
patients  becoming  somewhat  facile  and  too  content,  it  is  an  indication  that 
dementia  is  threatened,  but  simple  melancholia  is  of  all  mental  diseases  one 
of  those  least  subject  to  pass  into  dementia.     As  I  have  mentioned,  however, 


MENTAL     DISEASES  309 


hope  of  recovery  should  be  entertained  so  long  as  anything  like  decided  depres- 
sion of  mind  exists,  even  for  years.  I  have  known  a  case  of  melancholia  recover 
after  twenty  years.  If  the  disease  has  come  on  during,  or  in  consequence  of, 
an  epoch  in  life,  like  adolescence,  pregnancy,  or  the  climacteric,  recovery  may 
be  looked  upon  as  more  likely  when  such  an  epoch  has  passed  away.  Senility 
is  not  in  itself  an  absolute  bar  to  recovery.  I  shall  refer  to  the  fact,  when  1 
speak  of  senile  insanitj^,  that  its  melancholic  forms  recover  in  a  reasonable 
proportion  of  the  cases. 

Periodicity  and  Recurrence. — The  patients  themselves  and  their  relations 
are  nearly  always  anxious  as  to  whether  the  trouble  is  likely  to  return.  The 
prognosis  in  regard  to  this  must  be  somewhat  guarded  in  all  forms  of  mental 
disease,  which,  taken  all  together,  recur  in  about  20  per  cent  of  the  recoveries. 
Simple  melanchoha  is  not  a  disorder  that  is  specially  apt  to  recur  unless  the 
temperament  of  the  patient  is  an  extremely  sensitive  one.  A  certain  mental 
hyper-sensitiveness  of  disposition  is,  in  my  opinion,  the  psychological  basis 
on  which  most  cases  of  melancholia  are  implanted.  It  may  be  put  down,  in  fact, 
as  its  chief  predisposing  cause.  This  hyper-sensitiveness  is  so  extreme  in 
some  cases  that  its  unfortunate  possessors  may  be  said  to  be  always  on  the 
verge  of  simple  depression  of  mind.  I  had  a  lady  patient  once  who  was  liable 
to  be  thrown  into  such  a  condition  on  almost  the  slightest  occasion  of  worr5% 
distress,  disappointment,  or  loss.  She  had  several  attacks  when  she  lost 
relations,  she  had  one  when  her  favourite  dog  died,  and  she  could  never  stand 
a  too  exciting  sermon  at  church.  Some  persons  with  a  strong  neurotic  heredity 
of  brain  are  liable  to  depression  during  the  epochs  of  life  I  have  referred  to. 
Some  people  are  liable  to  an  attack  whenever  they  overwork  themselves, 
mentally  or  physically,  whenever  they  have  an  attack  of  indigestion,  or  whenever 
they  are  '  run  down.'  Taking  simple  melancholia  as  a  whole,  the  liability 
to  recurrence  or  periodicity  may  be  put  down  at  about  15  per  cent  of  all  the 
cases.  It  is  always  a  right  thing  for  the  doctor,  when  he  is  in  attendance  on 
such  a  case,  to  assure  his  patient  that  there  is  no  chance  of  recurrence  if  he  will 
keep  his  health  in  good  condition  and  adopt  means  of  treatment  at  the  very 
earliest  stage,  or  if  he  should  feel  the  least  symptom  of  depression,  loss  of 
weight,  or  sleeplessness.  I  advise  most  of  my  melancholic  recoveries  to  weigh 
themselves  regularly.  It  is  to  be  kept  in  mind  that  the  slighter  forms  of  depres- 
sion are  liable  to  occur  as  preludes  to  most  other  forms  of  insanity,  and  during 
the  very  first  part  of  those  attacks  the  doctor  has  to  think  of  this  in  his  prognosis. 

Other    Forms    of    Melancholia As    I    mentioned,    melancholia    occurs    in 

the  proportion  of  35  per  cent  of  all  the  cases  of  insanity  sent  to  institutions. 
Taking  all  the  cases  who  consult  doctors  privately  on  account  of  mental 
symptoms,  I  would  say  that  mental  depression  stands  in  the  proportion  of  at 
least  80  per  cent.  The  general  prognosis  of  all  forms  of  melancholia  is  repre- 
sented by  the  43-7  per  cent  which  I  have  referred  to.  While  the  simple  melan- 
cholia of  which  I  have  treated  is  by  far  the  most  curable  variety,  it  is  not  the 
only  one  that  is  curable. 

Suicide. — First  let  ns  look  at  the  most  serious  of  all  the  complications  of 
melancholia,  namely,  the  suicidal  impulse.  This  is  so  common  that  it  exists 
in  lesser  or  greater  degi-ee  in  about  four-fifths  of  all  the  cases  of  melancholia, 
but,  in  great  intensity  and  constituting  a  serious  risk,  it  only  applies  to  two- 
fifths  of  the  cases,  and  those  we  classify  as  emphatically  the  suicidal  variety. 
It  is  a  common  idea  that  when  a  patient  is  strongly  suicidal  he  is  therefore 
incurable.  This  is  certainly  not  a  correct  view.  Its  gravity  and  its  risks  should 
not  make  one  take  a  despairing  view  of  even  a  verj^  suicidal  case.  They  recover 
in  as  great  a  proportion  as  the  ordinary  cases  if  we  exclude  the  simple  variety. 


INDEX     OF     PROGNOSIS 


Delusional  Melancholia. — The  next  variety  of  melancholia,  which  we  call 
the  delusional  fonn,  is  much  more  serious  than  the  suicidal  in  the  prognosis. 
By  this  term  is  not  meant  melancholia  with  delusions.  It  is  used  to  indicate 
that  varietur  of  the  disease  in  which  a  delusion  or  delusions  are  from  the  beginning 
the  most  prominent  symptom,  in  which  they  remain  throughout  the  disease  of 
the  same  nature,  giving  the  attack  a  distinctive  character,  being  what  are 
called  fixed  delusions,  in  contradistinction  to  milder  delusions  that  change  in 
kind,  or  subject,  or  degree.  The  relatives  of  such  patients  are  apt  to  call  it 
the  cause  of  the  disease,  when  scientifically  it  is  merely  the  most  marked  symptom. 
The  real  disease  consists  of  the  depression,  the  mental  pain  which  is  at 
the  bottom  of  the  delusion  and  underhes  all  the  other  symptoms.  In  such  a 
case  of  delusional  melancholia  the  prognosis  is  undoubtedly  unfavourable, 
especially  if  the  delusions  last  for  over  the  first  six  months  of  the  case.  The 
delusional  cases  constitute  about  25  per  cent  of  the  melancholies.  The 
delusional  and  the  suicidal  symptoms  may  combine  in  the  same  case,  and  this 
constitutes  a  grave  prognosis. 

Homicidal  feelings  and  attempts  sometimes  occur  in  melancholia,  and  consti- 
tute a  grave  element  in  the  prognosis,  without,  however,  indicating  incurability. 
I  have  known  many  cases  of  simple  melancholia  with  vague  homicidal  feelings, 
but  the  real  danger  of  homicide  is  found  chiefly  in  the  excited  variety'  of  which 
I  am  about  to  speak,  and  at  the  beginning  of  the  attack. 

Excited  and  Resistive  Melancholia. — Extreme  agitation  and  excitement  as 
a  part  of  the  disease  may  be  the  distinguishing  characteristic  of  an  attack  from 
the  beginning  till  near  the  end  of  its  course,  or  it  may  occur  as  one  stage  in  its 
complete  clinical  history.  The  patients  in  such  cases  rush  about,  may  be 
violent  to  those  about  them,  wander  ceaselessly,  walk  up  and  down,  and  cannot 
sit  still  for  any  length  of  time,  roll  about  on  the  floor,  bite  their  finger-nails, 
or  wring  their  hands,  or  shout,  or  groan,  and  weep  loudh%  or  tear  their  clothes. 
In  short,  the  muscular  expressions  of  the  per\'ading  morbid  emotion  are  strong 
and  uncontrollable  by  their  wills.  This  really  constitutes  the  worst  varietv- 
of  the  disease,  and  by  far  the  most  difficult  to  manage,  rendering  institution 
treatment  necessary  in  almost  all  the  cases.  The  presence  of  this  agitation 
is  determined  either  by  the  intensity  of  the  disease  or  the  temperament  of  the 
patient.  The  Celtic  races  are  apt  to  show  it  more  than  the  Teutonic.  Delirium. 
trem.ens  in  the  acute  form  may  be  taken  clrnicall}-  as  representing  excited 
melancholia.  There  are  apt  to  be  hallucinations  of  the  senses  in  this  form, 
and  a  toxic  element  in  the  etiolog}'. 

Along  with  excitement,  or,  in  some  cases,  without  much  motor  excitement, 
there  are  cases  of  melancholia  which  are  intensely  obstinate  and  resistive 
in  their  conduct.  Thej-  will  not  go  to  bed,  they  wUl  not  undress,  they  will  not 
do  what  they  are  wanted  to,  and  some  of  them  are  stuperose  in  their  character. 
The  expression  of  face  in  those  cases  is  utterly  changed  from  the  normal.  The 
excited  and  resistive  varieties  constitute  what  is  often  called  '  acute  '  melan- 
choUa.  The  prognosis  in  such  cases  is  worse  than  in  any  form  of  the  disease. 
It  is  apt  to  run  on  into  a  chronic  condition,  or  the  patient  dies  of  exhaustion. 
Certainly  not  more  than  one-fourth  of  such  cases  recover.  Those  forms  are 
often  associated  also  with  a  strong  suicidal  tendencj'. 

Hypochondriacal  Melancholia. — A  somewhat  distinctive  form  of  the  disease 
is  characterized  by  hj-pochondriacal  sj-mptoms  in  which  the  mental  pain  has 
a  certain  want  of  intensity,  and  takes  the  form  of  fancies  which  centre  round  the 
patient's  own  health.  He  thinks  he  is  all  out  of  sorts,  that  his  digestion  is  -vvTong, 
that  his  stomach  is  all  out  of  order,  that  his  heart  is  weak,  that  he  is  certainly 
going  to  die  of  paralysis  or  some  other  trouble  which  is  really  imaginary.     There 


MENTAL     DISEASES  311 


are  no  limits  to  the  fancies  of  the  hjrpochondriac.  Now  this  class  of  symptom 
adds  considerably  to  the  gravity  of  the  prognosis.  Such  patients  are  not 
apt  to  recover  quickly,  and  more  than  one-half  of  them  do  not  recover  at  all. 
They  are  a  very  troublesome  class  to  the  doctor,  because  the  patient  is  con- 
tinually wanting  to  see  him  and  pour  out  accounts  of  his  imaginary  illnesses 
to  him.  Although  what  the  patient  complains  of  may  be  perfectly  unreal  as 
real  objective  facts,  5'et  they  represent  an  organic  sense  of  ill-being  and  are  quite 
real  to  his  consciousness.  There  is  little  risk  of  suicide  in  the  prognosis  in  those 
cases,  except  in  the  very  worst  class  of  them.  Suicide  is  often  talked  of  and 
threatened,  but  seldom  carried  out.  In  ordinary  cases  of  melanchoUa,  when  a 
patient  is  deeply  depressed,  he  says  little  about  suicide  but  thinks  a  great  deal 
of  it.  Those  are  the  really  dangerous  cases.  When  a  man  is  constantly  talking 
of  suicide,  as  sometimes  in  the  hypochondriac,  there  is  certainly  very  much  less 
risk  of  his  committing  the  act ;  but  still  I  have  known  it  occur  even  when  it  had 
been  much  spoken  of  previously. 

States  of  Depression  as  seen  in  Private  Practice. — The  statistics  of  these 
conditions  as  met  with  in  private  and  consultation  practice  are  perhaps  more 
instructive  to  the  general  practitioner  than  those  of  institutions,  even  if  they  are 
not  quite  so  exact.  The  patients  are  mostly  in  the  early  stages  of  the  disease, 
and  they  are  still  living  under  the  ordinary  home  conditions  of  treating  disease. 
They  are  in  every  way  more  analogous  to  cases  in  ordinary  practice.  As  the 
results  of  such  treatment  are  not  to  be  found  in  the  text-books,  I  give  them 
here. 

I  have  taken  the  last  200  consecutive  cases  that  I  have  seen  in  consultation 
and  have  analyzed  them.  I  find  of  the  200  there  were  104  who  laboured  under 
depression  of  mind,  who  mostly  knew  they  were  ill  and  had  themselves  desired 
or  were  persuaded  to  consult  a  mental  specialist  for  their  symptoms.  I  usually 
had  the  advantage  too — a  great  one — of  getting  the  previously  acquired  know- 
ledge of  the  family  doctor  as  to  the  patient's  previous  history  and  mental 
symptoms  that  had  appeared.  I  was  not  able  to  follow  the  mental  history  of 
all  those  patients — that  is  one  of  the  disadvantages  of  a  consultant.  At  least 
21  of  them  thus  passed  out  of  my  medical  knowledge.  But  I  know  that  88  of 
the  104  were  said  to  have  'recovered,'  that  is  a  total  recovery-rate  of  84  per 
cent.  That  represents  the  curability  of  the  present  attack  in  the  milder  cases  of 
melancholia.  If  one  relied  on  this  experience,  conditions  of  depression  would 
seem  to  be  a  very  curable  disease  indeed.  But  I  knew  many  of  them  would  be 
likely  to  relapse,  some  of  them  over  and  over  again.  My  inquiries  into  that 
point  brought  out  this  fact.  I  ascertained  that  36  of  them  had  recurrences  or 
relapses,  and  I  have  no  doubt  that  number  does  not  represent  the  full  facts. 
Deducting  this  36  from  the  88  '  recoveries,'  it  leaves  a  proportion  of  exactly 
one-half  as  being  possible  permanent  recoveries.  The  relapses  did  not  take 
place  in  many  of  the  patients  for  years,  so  that  in  those  cases  the  '  recoveries  ' 
were  just  as  real  as  recoveries  from  gout  or  rheumatism  and  many  other  diseases 
often  are.  I  knew  that  at  least  ten  of  those  relapses  passed  into  folie  circulaire, 
or  dementia,  or  other  incurable  mental  states.  Almost  all  those  patients  were 
in  comfortable  circumstances,  so  that  they  could  afford  to  obtain  skilled  nursing, 
changes  of  environment,  etc. 

Melancholia  is  apt  to  be  the  first  form  of  mental  disturbance  when  it  occurs 
in  any  family  up  to  that  time  free  from  it.  Being  the  sanest  form  of  mental 
disturbance,  it  is  the  most  curable  and  the  least  damaging  to  the  brain  when 
it  is  recovered  from. 

Premonitory  Symptoms. — In  the  early  stages  of  melancholia,  the  patients 
very  frequently  have  a  sense  of  impending  danger,  of  loss  of  self-control,  and 


312  INDEX     OF     PROGNOSIS 


that  they  may  take  away  their  own  lives.  This  feeling  causes  great  distress,  and 
aggravates  the  painful  s^onptoms  of  the  disease  very  much.  It  is  certainly  a 
symptom  that  is  not  to  be  disregarded  in  the  prognosis,  and  especially  in  regard 
to  the  precautions  to  be  taken.  The  patient  perhaps  does  not  speak  of  it  to 
anyone  but  his  doctor.  Relatives  usually  pooh-pooh  the  S3rmptom  as  not  being 
worth  taking  much  notice  of,  because  the  patient  at  the  time  is  self-controUed, 
and  can  pull  himself  together  and  look  ver\'  much  as  usual  in  the  presence  of 
strangers.  One  of  the  dif&culties  of  its  treatment  and  prognosis  is  this,  that 
constant  watching,  though  it  ma^^  be  necessary'  in  many  cases,  may  add  greatly 
to  the  patient's  depression,  thus  aggravating  the  disease  ;  the  watching  against 
the  symptom,  in  short,  acts  as  a  continual  suggestion  that  it  is  present.  There 
are  three  kinds  of  cases  which,  in  my  experience,  make  it  almost  impossible  to 
provide  absolutely  against  attempts  at  suicide.  Those  are,  first,  these  latent 
early  cases,  and  secondly,  those  where,  during  the  course  of  the  disease,  explosions, 
as  it  were,  of  suicidal  impulse  come  on  suddenly  %\'ithout  any  preUminary 
symptoms.  The  third  is  where  the  patient  exhibits  extreme  cunning  in 
concealing  his  impulses  and  extreme  determination  in  carr^dng  them  out.  As 
regards  the  doctor  in  attendance,  wherever  there  is  any  suicidal  impulse,  or  any 
reasonable  chnical  risk  of  it,  he  is  bound  to  take  precautions  and  to  intimate 
its  existence,  in  an  earnest,  impressive  way,  to  the  nurses  and  attendants  and  to 
the  responsible  relatives  of  the  patient. 

CoNDiTioxs  OF  Mental  Exaltation — ;\L\xia. 

Both  the  symptoms  and  the  prognosis  are  different  where  we  have  emotional 
and  intellectual  exaltation  as  the  chief  symptom,  as  compared  with  the  depression 
of  which  I  have  been  speaking.  Exaltation  in  any  form  is  a  more  insane  sj^mptom 
than  the  milder  degrees  of  depression.  The  patients  usually  do  not  recognize 
they  are  HI,  as  the  melanchohcs  so  frequently  do.  There  are  conditions  of  what 
may  be  called  physiological  exaltation,  as  in  healthy  childhood.  A  grown-up 
man  or  woman  who  behaved  like  such  a  child  would  be  in  a  condition  of  mental 
disorder.  Then  there  is  the  natural  exaltation  of  feeUng  resulting  from  good 
news  or  good  fortune.  This  maj',  in  some  cases,  pass  into  pathological  exaltation 
in  certain  temperaments.  A  certain  transitory  kind  of  morbid  elevation  is  apt 
to  occur  as  a  comphcation  of  fevers  and  other  diseases  in  children  of  a  strongly 
neurotic  temperament.  We  think  differenth*  of  conditions  of  depression  and  of 
exaltation.  The  former  we  are  apt  to  think  of  chiefly  from  the  patient's  own 
subjective  point  of  view,  the  latter  from  the  objective  evidences  of  his  conduct 
and  speech.  There  are  certain  conditions  of  exaltation  where  joy,  pleasure, 
and  happiness  are  the  characteristic  emotional  states,  and  there  are  others  where 
rage,  discontent,  and  irritability  are  its  chief  manifestations.  Most  cases  of 
mania  are  accompanied  by  '  excitement,'  that  is,  have  visible  muscular  acts 
as  its  sj^mptoms,  whereas,  in  simple  melanchoUa,  no  such  excitement  need  be 
present. 

As  a  clinical  fact,  mania  divides  itself  into  varieties,  just  as  melancholia 
does,  and  the  character  of  those  varieties  markedly  affects  the  prognosis  in 
individual  cases.  The  chief  of  those  varieties  are  the  simple,  the  acute,  the 
delusional,  and  the  chronic. 

Simple  Exaltation. — I  had  under  my  care,  during  the  ten  years  1S9S-1907, 
in  the  Royal  Edinburgh  Mental  Hospital,  800  cases  of  simple  mania  out  of  1754 
maniacal  cases  altogether,  and,  of  that  Soo,  348  recovered,  giving  a  favourable 
prognosis  of  43 '5  per  cent.  In  addition  to  those  recoveries,  a  certain  number 
more  were  discharged  relieved,  some  of  whom  no  doubt  completed  their  recov- 
eries after  leaving  the  institution,  but  there  were  not  nearly  so  many  of  such 


MENTAL    DISEASES  313 


relieved  patients  among  them  as  among  the  melancholies.  I  think  if  5  per  cent 
were  added  to  the  43  5  per  cent  of  recoveries,  it  would  represent  the  total 
curability  of  conditions  of  exaltation  so  marked  as  to  be  certified  insane.  This 
gives  a  prognosis  in  such  states  of  10-5  per  cent  less  than  that  an^ong  the 
depressed,  in  the  simple  varieties  of  the  disease. 

In  the  general  outlook  of  a  patient  who  suffers  from  morbid  mental  exaltation, 
there  are  different  risks  and  different  things  to  be  considered  from  those  suffering 
from  depression.  An  exalted  patient  will  commonh'  not  commit  suicide,  or 
think  of  it.  He  will  attract  more  attention  from  others  of  an  unfavouraole  kind ; 
he  will  be  looked  on  as  more  of  a  '  fool.'  He  will  have  far  more  chance  of  losing 
any  work  or  situation  he  has,  he  wiU.  be  more  likely  to  ruin  himself  by  foohsh 
action  or  speculation,  he  will  run  more  risk  of  getting  into  the  hands  of  the  pubhc 
authorities,  and  he  will  be  far  more  apt  to  produce  disturbances  in  his  family 
and  social  relations.  The  greatest  of  all  human  faculties,  that  of  will-power  and 
self-control,  is  very  much  more  weakened.  His  moral  sense  is  lessened  in  such 
a  way  that  he  is  liable  to  commit  acts  of  immorality ;  the  conventionalities  of  life 
are  lessened  in  him,  and  he  sets  them  aside.  In  his  dress,  and  in  the  company 
he  keeps,  he  changes  his  normal  habits.  He  is  much  more  frequently,  and  is 
sooner,  certified  to  be  insane  and  sent  to  an  institution  for  care  and  treatment, 
and  from  the  beginning  this  contingency  is  to  be  kept  in  mind  by  the  doctor  and 
explained  to  his  relations.  It  is  more  easy  to  persuade  relatives  that  this  step 
is  necessar}-  than  in  the  case  of  depression  of  mind.  Mental  exaltation  is  not 
so  apt  to  be  gradual  in  its  beginnings  as  depression.  It  comes  to  a  head  faster. 
There  are  fewer  cases  of  simple  mania  out  of  the  total  number  of  cases  of  exalta- 
tion as  compared  with  melancholia.  It  is  characterized  less  by  nutritional 
defects.  The  man  suffering  from  simple  mania  eats  weU,  sometimes  excessively, 
and  keeps  up  his  strength.  His  temperature  is  shghtl}-  higher  than  the  melan- 
cholic. Instead  of  putting  him  to  bed  and  giving  him  rest  and  massage  as  a 
form  of  treatment,  we  tend  in  most  cases  to  give  him  a  great  deal  of  exercise 
in  the  fresh  air,  to  put  him  to  dig,  or  to  send  him  away  on  a  walking  or 
bicycling  tour  with  his  attendant  or  a  friend.  We  are  far  less  sure  of  what  he 
wull  do  and  of  how  the  case  will  turn  out  than  where  we  have  simple  depression. 

Comparing  simple  exaltation  with  all  the  other  forms  of  mania,  the  percentage 
of  recoveries  is  only  about  3  per  cent  greater,  thus  showing  that  there  is  not  so 
great  a  difference  between  simple  mania  and  its  other  forms  as  between  simple 
melancholia  and  other  forms  of  depression.  It  is  in  fact  not  so  curable  a  disease. 
The  brain  is  more  disturbed  in  its  action  and  not  so  liable  to  recover  when 
exaltation  is  present  as  when  the  disturbance  consists  of  depression.  The  414 
cases  of  simple  depression  sent  to  the  institution  in  the  ten  years,  as  compared 
with  the  800  cases  of  simple  exaltation,  is  not  a  proof,  in  my  opinion,  that 
the  exalted  conditions  are  more  frequent,  but  that  they  are  of  a  character 
that  cannot  readily  be  managed  at  home  and  are  therefore  sent  to  asylums 
much  more  frequently. 

Recurrence. — I  have  no  quite  definite  statistics  showing  the  liability  to  recur- 
rence in  cases  of  simple  mania,  but  my  opinion  is  decided  that  it  is  more  liable 
to  recurrence,  and  certainly  it  is  more  liable  to  pass  into  other  and  deeper 
forms  of  mental  disease,  than  states  of  depression. 

Acute  Mania. — This  state,  being  the  most  vivid  and  dramatic  of  all  forms  of 
mental  disease,  is  very  often  taken  as  the  t>-pe  of  all  the  insanities.  It  is  the 
'  raving  madness  '  of  literature.  It  is  the  least  rational,  the  least  conscious, 
the  most  noisy,  and  most  unmanageable  of  all  the  forms  except  general  paralysis. 
Unfortunately,  being  thus  so  very  distinctive,  it  has  affected  the  conception, 
the  treatment,   and  the  prognosis   of   all   forms   of   mental    disease   in   a  very 


314  INDEX     OF     PROGNOSIS 

unfavourable  way  until  recent  times.  The  man  in  the  street  thinks  of  every- 
case  of  mental  disease  as  of  this  type.  Its  treatment  in  old  times  consisted  of 
manacles,  chains,  darkness,  and  stripes,  and  its  prognosis  was  usually  put  down 
as  entirely  hopeless.  It  is  not  really  a  common  variety  of  mental  disease,  for, 
out  of  2377  admissions  into  the  Royal  Edinburgh  Mental  Hospital  during  the 
seven  years  1874-1880,  only  297,  or  about  8  per  cent,  were  so  classified. 

Acute  mania  begins  in  various  ways,  sometimes  by  the  condition  of  simple 
mania,  but  often  quite  suddenly.  At  times  it  has  the  melancholic  prelude  to 
which  I  have  alluded.  Bodily  symptoms  are  more  apt  to  be  present  than  in  most 
varieties  of  insanity  except  general  paralysis.  The  temperature  is  raised,  weight 
is  rapidly  lost,  and  great  exhaustion  occurs  in  a  short  time  in  most  cases.  The 
prognosis  as  regards  recovery  is  not  nearly  so  bad  as  was  formerly  thought. 
My  experience  was  that  60  per  cent  of  the  asylum  cases  recovered,  yj  per  cent 
died,  32^  passed  into  chronic  mania  and  dementia.  This  liability  to  a  fatal  issue 
is  greater  than  in  any  other  form  of  mental  disease  except  puerperal  insanity  and 
general  paralysis.  There  is  no  form  of  mental  disease  where  there  is  more 
liability  to  the  brain  losing  its  higher  powers  of  mind  and  sinking  into  an  incurable 
mental  condition.  That  in  fact  is  the  greatest  risk  of  all,  and  the  greatest 
anxiety  to  the  doctor  who  is  responsible  for  its  treatment.  There  is  a  very  acute 
form  of  mental  disease,  called  by  many  authors  '  delirious  mania,'  or  acute 
delirium,  which  clinically  may  be  reckoned  as  the  worst  type  of  acute  mania. 
In  that  form  the  prognosis,  in  regard  both  to  recovery  and  to  death,  is  verj' 
much  worse  than  in  ordinary  acute  mania.  Some  authors  say  that  delirious 
mania  is  almost  invariably  fatal,  but  that  is  not  my  experience.  In  some  books 
this  is  called  typho-mania.  The  present  opinion  in  psychiatry  tends  to  put  down 
almost  all  cases  of  delirious  mania,  and  many  of  acute  mania,  as  being  forms  of 
brain  toxaemia,  although  no  specific  organism  has  as  yet  been  detected.  Certainly 
the  high  temperature,  and  many  of  the  other  symptoms,  point  to  a  toxin  whose 
action  has  focussed  itself,  as  it  were,  on  the  higher  cortical  brain  cells. 

Good  Indications  for  Prognosis. — If  the  disease  has  come  on  suddenly,  if  the 
great  organic  functions  of  the  body  are  not  especially  affected,  these  are  of  course 
good  signs.  If  the  stomach  and  bowels  and  digestion  are  acting  in  a  normal  way. 
if  the  heart's  action  is  not  unduly  weakened,  if  the  temperature  does  not  rise 
above  101°,  if  the  common  sensation  is  not  unduly  impaired,  if  the  mucous 
membranes  of  the  mouth  and  throat  are  not  dry,  if  weight  is  not  lost  at  the  rate 
of  more  than  four  pounds  a  week,  and  if  the  general  strength  shows  no  sign  of 
exhaustion  during  the  first  fortnight,  then  we  may  have  good  hopes  of  the 
patient's  ultimate  recovery  under  proper  treatment.  If  the  patients  begin 
rapidly  to  put  on  weight,  it  is  perhaps  the  most  favourable  bodily  sign 
of  approaching  recovery  that  can  appear.  If  the  disease  does  not  last  in  its 
acute  form  more  than  a  month,  if  there  are  no  signs  of  a  general  enfeeblement  of 
mind  after  the  first  six  or  twelve  months,  if  there  is  no  tendency  to  fixed  delusion, 
those  are  all  good  indications  in  the  prognosis.  Nowadays  we  commonly  put 
our  acutely  maniacal  patients  to  bed  for  the  first  few  weeks,  and  if  this  is  success- 
ful in  calming  them,  we  look  on  it  as  a  favourable  indication.  If  prolonged 
bathing  treatment  is  adopted,  and  the  patients  submit  to  this  quietly  and  are  the 
better  for  it,  that  shows  that  the  attack  will  probably  be  recovered  from.  If  this 
treatment  by  warm  baths,  with  perhaps  the  use  of  mild  sedatives,  has  the  result 
of  soothing  the  patients'  excitement  in  a  marked  way,  their  recovery  will  probably 
be  speedy.  If  the  habits  are  not  very  uncleanly  and  improve  under  care  it 
is  a  good  sign. 

Unfavourable  Indications. — If  the  temperature  is  persistently  over  101°,  if 
the  loss  in  weight  amounts,  as  I  have  seen  in  some  cases,  to  fourteen  pounds  in  a 


MENTAL    DISEASES  315 


week,  if  the  mucous  membranes  are  persistently  dry,  if  there  is  a  '  muttering 
delirium  '  at  night,  and  if  there  are  marked  signs  of  general  exhaustion  with 
heart  failure,  these  are  all  unfavourable  indications  as  to  recovery  and  life. 
Some  cases  of  acute  mania  die  from  exhaustion  in  spite  of  everything  that  can 
be  done,  and  some  of  these  die  very  quickly  and  suddenly,  within  the  first 
fortnight.  We  now  think  that  in  such  cases  the  toxaemia  has  been  of  a  very 
acute  character.  If  there  have  been  hallucinations  of  the  senses  and  they  show 
a  tendency  to  persist,  it  is  an  unfavourable  sign.  If  the  acute  symptoms  are 
entirely  intractable  and  go  on  for  perhaps  a  year  without  much  change,  we  fear 
that  it  may  pass  into  chronic  mania.  But  the  result  which  we  dread  above  all 
things  is  that  of  dementia,  of  which  I  have  spoken,  and  the  early  symptoms  of 
this  consist  of  a  diminution  of  the  active  maniacal  symptoms,  a  blurring  and 
deterioration  of  the  expression  in  the  face  and  eye,  a  lack  of  the  power  of  atten- 
tion to  what  is  going  on,  a  want  of  interest  in  the  people  about  him,  or  in  suitable 
occupation,  a  persistent  lack  of  orientation,  and  a  lowered  emotional  condition, 
with  a  loss  of  social  instinct  and  the  persistence  of  very  dirty  habits- — all  these 
are  unfavourable  indications  for  complete  recovery,  especially  if  the  patient  is 
in  the  period  of  adolescence.  They  mean  that  the  brain  cells  are  undergoing 
demonstrable  deterioration  or  atrophy.  This  affects  at  least  50  per  cent  of  all 
the  cells  in  bad  cases. 

Tendency  to  Recurrence  or  Complete  Recovery. — Acute  mania  is  a  condition 
which  is  not  apt  to  recur,  and  when  it  has  been  of  short  duration  it  may  be 
completely  recovered  from  and  leave  the  brain  and  the  man  in  a  normal  condition. 

Chronic  Mania. — This  is  really,  as  to  its  symptoms,  acute  mania  somewhat 
modified  in  certain  particulars  and  running  a  chronic  course.  I  put  down  the 
time  limit  here  as  twelve  months,  but  there  are  undoubtedly  some  cases  of  acute 
mania  who  recover  after  that  time.  Chronic  mania  is  an  incurable  disease,  but 
many  patients  live  a  long  time  suffering  from  this  condition.  There  is  a  spice  of 
enfeeblement  of  mind  in  chronic  mania,  the  memory  is  impaired,  the  habits  and 
fine  feelings  are  degraded  or  dulled,  the  emotional  power  and  social  instinct  are 
usually  almost  paralyzed,  and  the  power  of  attention  usually  much  lessened, 
although  some  patients  are  extremely  sharp  and  observant. 

Delusional  Mania. — Some  cases  of  mania  have  from  the  beginning  a  strong 
and  fixed  delusional  element  on  which  the  symptoms  of  excitement  seem  to  hang. 
A  man  believes  that  he  has  been  persecuted  by  his  relations  and  friends,  and  he 
seems  to  get  excited  in  consequence  of  this  delusion.  I  had  a  patient  who  shouted, 
scolded,  and  was  violent,  almost  all  day,  alleging  as  the  reason  of  her  conduct 
that  her  children  were  below  the  boards  of  the  lioor,  and  that  she  heard  them 
constantly  being  tortured  by  villains  who  were  killing  them.  The  prognosis  in 
this  form  of  mania  is  certainly  unfavourable,  though  individual  cases  sometimes 
recover.  It  is  often  accompanied  by  vivid  hallucinations  both  of  hearing  and 
sight,  and  these  are  unfavourable,  particularly  the  auditory  hallucinations  if  they 
last  long. 

Mania  in  all  its  Forms. — Statistics.  Taking  every  form  of  morbid  mental 
exaltation,  I  had  1757  cases  in  the  Royal  Edinburgh  Asyluin  during  the  ten 
years  I  have  referred  to,  of  which  715  recovered,  which  gives  a  percentage  of  40-7, 
being  3  per  cent  less  than  that  of  melancholia,  and  I  think  that  the  patients  who 
were  discharged  relieved  did  not  recover  at  home  in  anything  like  the  same 
proportion  as  the  melancholies  did.  About  5  per  cent  may  be  added  to  the 
40-7,  making  about  45  per  cent  as  a  general  prognostic  chance  in  mania.  The 
whole  number  of  cases  of  mania  were  1757,  as  compared  with  the  1465  melan- 
cholies, during  the  ten  years;  but,  as  1  have  stated,  this  does  not  represent 
the  real  liability  to  depression  and  exaltation  of  mind  in  the  population. 


3i6  INDEX     OF     PROGNOSIS 

Turning  to  conditions  of  morbid  exaltation  seen  in  private  practice,  I  had 
31  of  these  out  of  200  consecutive  cases,  or  12  per  cent,  contrasting  thus 
with  the  52  per  cent  of  cases  of  depression.  Twelve  of  the  31  recovered, 
a  percentage  of  39,  as  compared  with  the  88  per  cent  of  the  melancholies.  I 
ascertained  that  5  out  of  the  12  recoveries  had  relapses,  or  41  per  cent,  which  is 
the  same  proportion  as  the  melancholies.  The  lesser  number  of  elevated  cases 
I  saw  as  compared  with  the  depressed  may  not  necessarily  prove  a  lesser  occur- 
rence of  morbid  elevation  in  the  brain  working  of  the  community,  but  to  the 
fact  that  patients  suffering  from  mania  are  not  so  apt  to  come  or  be  brought  to 
a  consultant.  They  usually  do  not  recognize  they  are  iU,  and  they  are  so 
decidedl}^  more  insane  that  they  are  much  more  apt  to  be  removed  to  mental 
hospitals  at  once.  The  lesser  percentage  of  recoveries  I  met  with  in  private 
practice  among  the  cases  of  mania  may  be  partly  accounted  for  through  the 
greater  mildness  and  manageability  of  the  symptoms  in  melanchoha,  so  that 
many  more  of  them  could  be  treated  at  their  homes  or  in  rooms  during  the 
curable  stage  of  their  attacks. 

'Manic-depressive'  Mental  Disease. —  All. authors  on  mental  diseases  had 
noticed  a  certain  relationship  between  cases  of  mania  and  melancholia.  I  stated 
in  my  "  Clinical  Lectures  "  that  "  there  exists  in  the  majority  of  nearly  all  the 
acute  cases,  at  some  time  or  other,  in  some  form  or  degree,  in  some  stage  of  the 
disease,  a  tendency  to  alternation,  periodicity  of  symptoms,  remissions,  or 
recurring  relapses."  I\Iy  statistics  showed  that  about  44  per  cent  of  all  my  cases 
of  insanity  showed  those  characteristics,  but,  by  confining  ourselves  to  cases 
of  mania  and  melancholia,  at  least  46  per  cent  had  those  characteristics.  All 
phj^sicians  in  charge  of  mental  hospitals  knew  that  certain  cases  of  mania  maght 
become  depressed,  and  vice  versa,  during  the  same  attack,  also  that  a  patient 
might  come  in  at  one  time  with  mania  and  his  next  attack  would  be  melancholia. 
We  all  considered  that  those  two  conditions  had  a  certain  relationship  to  each 
other,  but  it  was  reserved  for  Kraepehn,  of  INIunich,  to  throw  the  two  conditions 
into  one  for  purposes  of  classification  and  call  it  '  manic-depressive  insanity.' 
He  maintkined  that  a  very  large  number  of  cases  of  either  condition  actually  had 
some  symptoms  of  the  other,  if  the  whole  mental  life  were  taken  into  consideration. 
His  subsequent  experience  and  more  careful  study  of  the  subject  has  led  him  to 
the  belief  that  there  are  practically  no  cases  of  mania  that  have  not  had  a 
melanchohc  phase,  and  that  there  are  perhaps  a  few  more,  but  not  m.a.ny,  cases 
of  melanchoha  that  have  not  a  maniacal  phase.  His  general  conclusion  from 
those  facts  is  that,  in  essential  nature  and  as  forming  the  basis  of  a  true  classi- 
fication, they  all  ought  to  be  thrown  together  and  called  by  one  term — not  two. 
That  there  is  a  great  deal  in  this  view  few  of  us  doubt,  but  our  experience  as  to 
the  almost  universal  frequency  of  the  association  of  the  two  conditions  has  not 
been  the  same  as  that  of  Kraepelin.  Either  we  have  not  observed  those  phases, 
or  Kraepelin  has  been  biassed  and  has  seen  slight  depressions  and  elevations 
which  have  not  been  visible  to  most  psycMatrists.  From  a  clinical  point  of 
view,  especially  as  to  treatment  and  management,  a  case  of  depression  is  largely 
different  from  one  of  mania,  and,  as  we  have  seen,  the  prognosis  is  different. 
One  can  scarcely  imagine  telling  the  relatives  of  a  tj-pical  case  of  simple  depression 
of  mind  that  it  is  one  of  '  manic-depressive  insanity.'  It  would  obviously  be 
more  satisfactory  and  intelligible  to  both  the  medical  attendant  and  to  the 
relations  to  call  it  a  case  of  mental  depression.  The  psychological,  and  especially 
the  emotional  condition,  in  the  two  varieties  is  so  essentially  different  and 
opposite  that,  even  from  a  scientific  view,  Kraepelin's  classification  does  not 
seem  altogether  satisfactory.  It  is  only  in  the  verv-  decided  cases,  where  the 
depressed   and   elevated    states   alternate   regularl}^   and    ha\'e   a   definite   and 


MENTAL     DISEASES  317 


calculable  relationship  to  each  other,  that  we  are  bound  to  regard  them  as 
different  phases  of  the  same  brain  condition. 

The  general  prognosis  in  Kraepelin's  manic-depressive  insanity  is  represented, 
according  to  my  experience,  by  a  42  per  cent  recovery-rate  in  the  cases  treated 
in  institutions,  and  if  we  add  8  per  cent  for  recoveries  at  home,  we  arrive  at  a 
prognostic  chance  of  50  per  cent. 

States  of  Marked  and  Regular  Alternation  and  Periodicity — '  Folic  Circulairc' — 
This  is  not  the  place  to  go  into  the  most  interesting  subject  of  the  physiological 
periodicity  of  function  in  all  living  creatures,  except  in  so  far  as  it  relates  to 
prognosis  in  raental  diseases.  The  two  most  marked  periodicities  in  man  are 
sleep  and  the  processes  of  reproduction.  Both  are  disturbed  in  mental  disease, 
and  disturbances  in  both  markedly  affect  its  symptoms  and  prognosis.  We 
cannot  dissociate  the  physiological  periodicities  from  the  pathological  alternations 
and  similar  changes  in  disease.  Many  recurrences  and  changes  in  mental 
disturbances  are  accounted  for  by  reference  to  the  physiological  periodicities, 
especially  in  youth,  when  we  have  to  do  with  sex  and  menstruation.  An  attack 
of  mental  depression  or  of  elevation  may  be  a  pathological  representative  of  the 
physiological  effects  of  menstruation.  If  we  have  such  a  pathological  mental 
periodicity  established,  as  a  morbid  habit  it  is  very  difficult  to  get  rid  of,  as  might 
have  been  expected  from  this  relationship  to  a  physiological  process.  The 
prognosis  therefore  becomes  bad  in  such  a  case. 

There  is  no  doubt  that  when  we  have  a  neurotic  diathesis  and  a  bad  brain 
heredity  we  are  more  apt  to  have  an  exaggeration  of  the  physiologcal  periodi- 
cities in  the  direction  of  disease.  Everybody  who  observes  men  and  women 
from  a  psychological  point  of  view  knows  that  the  slight  morning  change  of 
mental  condition,  as  compared  with  the  evening,  which  may  be  said  to  be 
physiological,  is  greatly  exaggerated  in  the  neurotic  subject,  taking  the  form 
of  a  regular  morning  depression  or  want  of  power  of  energizing,  or  some  vague 
feeling  of  organic  discomfort.  Few  men  and  women  of  the  finer  and  more 
sensitive  artistic  temperament  but  experience  some  such  feeling,  and  we  have 
seen  that  simple  melancholia  often  has  the  same  features.  The  periodicities  of 
morning  and  evening  temperature  are  markedly  altered  in  the  acute  insanities. 
There  is  no  more  common  symptom  in  all  forms  of  recent  mental  disease  than 
insomnia,  which  means  the  ceasing  of  a  brain  periodicity.  Seasonal  periodicities 
exhibit  themselves  in  many  of  the  neurotic  and  the  insane.  They  are  not  always 
in  the  same  condition  of  mind  in  the  spring  as  in  summer.  Some  such  people 
are  subject  to  moods,  cravings,  obsessions,  and  tempers  periodically.  There  are 
many  persons  whose  mental  life  is  one  long  alternation  of  action  and  reaction, 
activity  and  torpor,  as  if  by  a  natural  law  of  their  organization.  There  are  very 
few  of  the  neuroses,  in  addition  to  the  mental  disturbances,  that  are  not  more  or 
less  periodic  ;    for  instance,  neuralgia,  asthma,  megrim,  and,  above  all,  epilepsy. 

There  is  a  form  of  mental  disease,  called  folic  circulairc,  first  described  by 
French  medical  authors,  in  which,  when  it  occurs  in  a  typical  form,  there  are 
weeks  or  months,  or  even,  in  some  cases,  years  of  morbid  depression,  followed  by 
somewhat  the  same  periods  of  morbid  elevation,  and  then  by  a  condition  which 
is  practically  sanity.  This  sequence,  forming  a  kind  of  circle  with  three  sections, 
goes  on  during  the  whole  life-time  of  the  patient  in  most  cases.  Once  fairly 
established  the  prognosis  is  extremely  bad.  In  my  experience  there  are  not 
more  than  5  per  cent  of  recoveries.  The  terminations  of  this  disease,  other  than 
those  few  cases  of  recovery,  are  :  first,  exhaustion  during  the  maniacal  phase 
of  the  disease  ;  second,  death  iiora  old  age  at  the  usual  periods  of  life  ;  third, 
a  sort  of  settling  down  into  either  a  milder  form  of  periodicity  or  into  a  stuperose 
condition  during  old  age.     Nearly  20  per  cent  undergo  this  change.     Very  few 


3i8  INDEX     OF     PROGNOSIS 

indeed  of  such  cases  pass  into  dementia,  however  acute  the  elevated  phases 
may  have  been. 

In  the  majority  of  cases  of  my  '  adolescent  insanity  '  there  is  a  tendency  to 
remission  and  periodicity  before  either  recovery  or  dementia  set  in,  and  w^e  must 
be  very  careful  in  the  diagnosis  and  prognosis  not  to  pronounce  them  cases  of 
folie  circulaire.  In  fact,  we  must  have  several  years'  duration  and  very  many 
successive  and  regular  states  of  alternation  before  we  definitely  make  the  diagnosis. 

Patients  suffering  from  folie  circulaire  usually  live  long.  The  acuter  cases 
are  very  troublesome,  and  usually  need  institution  treatment,  but  there  are 
many  people  in  the  world  who  have  what  is  virtually  a  very  mild  form  of  folie 
circulaire,  and  during  the  elevated  periods  do  uncommonly  good  and  sometimes 
brilliant  work,  and  during  the  depressed  periods  are  simply  '  lazy,'  stupid,  and 
inactive.  They  do  not  need  to  be  put  under  care  at  all.  I  could  quote  from 
literature  many  examples  of  men  who  put  out  their  best  work  during  periods  of 
slight  mental  exaltation. 

The  favourable  indications  in  folie  circulaire,  in  the  rare  cases  where  such  are 
met  with,  are  a  lengthening  in  the  periods  covered  by  the  whole  circle,  a  mitigation 
in  their  character,  and  an  improved  self-control  during  the  period  of  elevation, 
the  depression  being  less  intense  and  the  elevation  less  maniacal.  I  have  been 
in  the  habit  of  trying  in  the  early  stages  of  folie  circulaire  to  control  and  stop 
the  elevation  by  the  use  of  the  bromides,  sometimes  combined  with  sulphonal 
and  cannabis  indica.  I  think  I  can  say  that  in  a  certain  number  of  cases  this 
has  been  done  and  the  morbid  mental  brain  habit  has  been,  as  it  were,  stopped. 
This  is  worth  trying,  but  I  can  recall  one  or  two  cases  where  the  result  of  this 
treatment  has  been  that  the  patients  sink  into  a  kind  of  lethargy  and  do  not 
come  out  of  it,  ceasing  to  have  any  elevations  and  depressions.  On  inquiring 
into  family  history  we  find  that  cases  of  folie  circulaire  have  nearly  always 
a  mental  or  a  neurotic  family  history.  It  is  found  in  a  typical  form  more 
frequently  in  members  of  '  old  '  families,  and  many  such  families  have  had 
other  members  of  great  intellectual  distinction. 

Delusional  Conditions — Monomania,  Paranoia. — Delusion  is  a  term  which  is 
not  easy  of  definition.  It  has  a  popular  and  a  medical  meaning.  If  any  man 
or  woman  has  a  fixed  belief  in  something  that  would  be  incredible  to  people  of 
the  same  class,  education,  or  race  as  the  person  who  expresses  it,  this  belief 
persisting  in  spite  of  proof  to  the  contrary,  we  say  he  or  she  has  a  fixed  delusion. 
If  such  a  delusion  continues  month  by  month  and  year  by  year,  the  prognosis 
is  extremely  unfavourable.  It  is  only  in  exceptional  cases  that  such  persons 
recover  and  do  good  work  in  the  world.  The  fixity  in  such  cases  is  the  character 
which  means  the  incurability.  Such  false  beliefs  and  delusions  may  assume 
almost  every  character.  They  may  refer  to  the  patient  himself,  his  health, 
his  organic  and  primary  instincts,  such  as  sex,  food,  and  social  relations,  or 
they  may  be  of  a  general  and  impersonal  nature,  referring  to  society,  to  other 
individuals,  to  political  matters,  etc.  They  may  or  may  not  be  accom- 
panied by  hallucinations  of  the  senses,  but  if  they  are  so  it  is  a  particularly 
incurable  sign.  A  man's  whole  mental  life  may  be  of  a  delusional  character, 
or  it  may  refer  to  one  subject  alone,  in  which  case  it  is  called  monomania. 
Delusional  conditions  are  usually  divided  psychologically  into  two  kinds,  one  of 
elevation  and  often  unreasonable  happiness,  the  other  of  persecution,  suspicion, 
unseen  agencies,  and  irritability,  danger,  and  general  unhappiness  in  life. 
Delusional  insanity  is  often  founded  on  the  temperament  of  the  individual. 
Vain  men  fall  into  the  delusion  that  they  are  much  more  able  or  hold  higher 
positions  than  is  the  case.  Suspicious  men  get  to  believe  that  their  relatives  and 
friends  or  society  are  persecuting  them. 


MENTAL    DISEASES  319 


A  modern  psychiatrist,  when  he  is  consulted  about  a  case  where  there  is  a 
tendency  to  insane  delusion,  or  where  there  are  hallucinations  of  recent  origin, 
first  looks  out  for  some  bodily  cause  of  this  brain  and  mental  change.  He 
endeavours  to  ascertain  whether  there  is  any  toxin  circulating  in  the  brain  from 
without  the  body  or  from  within.  It  is  one  of  the  common  results  of  the  excessive 
use  of  alcohol,  to  find  delusions  of  suspicion  and  hallucinations  of  the  senses. 
The  syphilitic  poison  often  produces  the  same  result.  I  believe  the  toxic  eiJects 
of  the  breaking  down  of  the  tubercle  bacilli  in  phthisical  patients  sometimes 
causes  mental  disturbances  through  their  action  on  the  brain  cells — a  condition 
which  I  have  called  '  phthisical  insanity.'  There  is  a  rare  but  well-known  form 
of  mental  disturbance  which  is  liable  to  occur  during  attacks  of  acute  rheumatism, 
which  is  undoubtedly  caused  by  the  rheumatic  poison  or  micro-organism.  There 
are  also  the  myxoedematous  and  exophthalmic  forms  of  mental  disturbance.  I 
would  advise  every  medical  practitioner  not  to  come  to  an  absolutely  unfavour- 
able prognosis  in  cases  of  delusional  insanity  before  he  has  made  a  thorough  inves- 
tigation into  such  possible  bodily  causes  for  the  disease  and  estimated  the  chances 
of  counteracting  or  getting  rid  of  them.  No  doubt  toxins  may  have  the  effect 
of  damaging  the  brain  cells  irretrievably,  but  in  some  cases  of  delusion  they  may 
be  counteracted,  and  in  that  way  the  patient  cured  if  taken  in  time.  Of  recent 
years  many  of  our  younger  psychiatrists  have  been  trying  the  effects  of  various 
serums  and  vaccines  used  in  the  early  stages  of  such  cases,  as  cures  and  counter- 
actives, but  their  success  has  not  as  yet  been  great.  This  is  a  field,  however, 
from  which  we  hope  much  in  the  more  acute  toxaemias,  but  I  cannot  say  that 
in  the  cases  of  paranoia  there  has  been  as  yet  much  success  except  in  certain 
cases  of  syphilitic  origin,  and  then  I  have  seen  marked  benefit,  and  even 
cure,  by  the  use  of  antisyphilitic  remedies,  combined  of  course  with  moral  and 
mental  treatment,  occupation,  changes  of  environment,  etc.  There  are  now  a 
considerable  number  of  cases  on  record  where  a  condition  of  fixed  delusion 
was  caused  by  traumatic  injury  to  the  head,  and  where  surgical  operation  by 
trephining  cured  the  disease. 

There  is  a  legal  aspect  of  insane  delusion,  as  there  may  be  in  most  forms  of 
mental  disease,  where  we  have  homicide,  suicide,  and  serious  bodily  injuries, 
done  as  the  result  of  delusions.  It  is  often  important  to  be  able  to  give  evidence 
that  such  cases  are  the  result  of  mental  disease.  There  are  a  certain  number  of 
the  cases  of  paranoia  where  delusions  are  concealed,  and  their  presence  is  even 
consistent  with  occupying  positions  of  responsibility  and  doing  good  work  in 
the  world.  In  such  cases  the  prognosis  specially  applies  where  wills  are  made 
and  are  influenced  by  the  delusions  present  in  the  patient's  mind.  I  have 
been  frequently  consulted  about  persons  with  delusions  but  who  have  exhibited 
them  to  no  one  except  their  nearest  relations. 

Magnan,  of  Paris,  has  described  a  "  progressive  systematized  delusional 
insanity,"  characterized  by  four  stages  :  (i)  Insane  interpretations  and  slight 
depression  ;  (2)  Ideas  of  persecution,  with  hallucinations  of  hearing  ;  (3)  Delu- 
sions of  grandeur,  and  (4)  Dementia.  My  experience  is  that  this  systematic 
course,  while  it  undoubtedly  is  seen  in  some  cases,  is  a  rare  one.  Delusional 
insanity  is  sometimes  a  part  of  that  '  degeneracy  '  and  '  hysteria  '  which  Max 
Nordau  so  vividly  describes  as  influencing  our  present-day  literature  and  art. 
If  this  is  so,  and  where  it  exists,  it  is  certainly  an  incurable  human  tendency. 

Defective  Control,  Insane  Impulse,  Insanity  without  Delusion,  Exaltation,  De- 
pression, or  Enfeeblement. — There  can  be  no  doubt  that  man's  power  of  will,  his 
self-control,  and  his  ability  through  the  exercise  of  his  vohtion  to  regulate  his 
conduct  so  that  he  lives  within  the  limits  of  the  law  and  of  good  morals,  is  his 
highest  faculty.     When  this  great  power  fails  in  a  marked  degree  and  men  and 


320 


INDEX     OF     PROGNOSIS 


women  act  from  pure  unreasoning  impulse,  and  especially  if  such  action  is  sudden 
and  explosive,  it  undoubtedly  means  disease.  Under  the  influence  of  such 
uncontrollable  impulses  suicide  and  homicide  are  sometimes  committed,  and 
many  crimes  and  anti-social  acts  result.  Such  loss  or  weakening  of  the  power  of 
mental  inhibition  must,  however,  be  very  marked  to  class  it  as  a  disease.  After 
all,  control  in  all  men  is  a  question  of  degree.  Mental  inhibition  is  a  faculty 
which  does  not  exist  in  early  childhood,  and  it  grows  during  childhood  and 
adolescence  just  as  bodily  powers  and  faculties  develop.  A  careful  study  of 
different  children  shows  that  there  is  an  extraordinary  difference  between  the 
degree  and  the  development  of  this  power  in  different  children  of  the  same  ages. 
That  development  is,  or  should  be,  associated  with  a  growing  sense  of  right  and 
wrong,  and  of  duty  in  regard  to  parents,  relations,  society,  and  the  Almighty. 
There  are  cases  where  such  power  of  action  and  such  a  sense  of  right  and  wrong 
is  never  developed  at  all.  We  now  call  such  '  moral  imbecility,'  and  for  the 
first  tim'^  this  condition  has  lately  been  recognized  in  Bills  before  Parliament, 
and  statutory  provisions  are  now  proposed  for  the  care  of  such  persons,  just  as 
we  have  similar  provisions  for  the  care  of  the  insane.  The  Royal  Commission  on 
the  Care  and  Control  of  the  Feeble-minded  thus  defined  such  moral  imbeciles  : 
"  Persons  who,  from  an  early  age,  display  some  mental  defect,  coupled  with 
strong  vicious  or  criminal  propensities,  on  which  punishment  has  little  or  no 
deterrent  effect."  It  will  be  observed  that  the  words  "  mental  defect  "  are 
used  by  the  Commissioners,  and  it  is  quite  true  that  there  is  a  real  mental  defect 
which,  in  most  cases,  involves  the  intelligence  and  the  emotions ;  but  there  is  a 
condition  of  loss  of  will-power^.and  moral  sense  in  a  few  grown-up  men  and 
women  without  intellectual  impairment.  Some  such  are  sometimes  extremely 
acute  intellectually,  and  use  that  ability  to  the  detriment  of  society.  They  have 
been  called  "  congenital  and  instinctive  criminals."  Most  fortunately  for  society 
such  persons  are  rare.  When  this  condition  of  moral  and  inhibitory  defect 
exists,  after  a  careful  inquiry,  and  after  taking  into  account  the  effects  of 
bad  enviroment,  bad  example,  and  no  moral  teaching,  its  subjects  may  be  pro- 
nounced as  quite  incurable.  Society  must  forcibly  segregate  them,  as  indeed 
is  proposed  in  the  Report  of  the  Commission  I  have  referred  to.  They  usually 
come  out  of  insane  ancestry. 

Dipsomania. — The  most  common,  and  to  society  the  most  troublesome,  of  those 
uncontrollable  impulses  and  moral  defects  is  that  of  craving  for  alcohol,  opium, 
cocaine,  and  such  drugs.  They  have  been  called  '  dipsomania,'  '  morphino- 
mania,'  etc.  There  are  many  fornis  of  drunkenness,  some  of  which  are  curable, 
but  the  true  dipsomania  is,  in  ninety-nine  cases  out  of  a  hundred,  an  incurable 
malady.  It  is  a  real  disease.  It  is  often  recurrent  and  periodic  in  its  symptoms,  and 
a  careful  psychological  study  of  a  number  of  cases  has  led  many  physicians,  myself 
among  the  number,  to  the  conclusion  that  one  usually  finds  associated  with  the 
drink-craving  more  or  less  of  a  real  mental  weakness  in  character,  in  intellect,  and 
common-sense,  as  well  as  will-power.  The  effects  of  the  excessive  use  of  alcohol 
have  been  so  injurious  to  society  that  many  Government  Commissions  have 
been  appointed  to  investigate  the  causes  and  to  suggest  remedies,  while  books 
without  number  by  doctors  and  laymen  have  been  written  on  the  subject.  1  was 
lately  a  member  of  a  Departmental  Committee  which  investigated  the  subject 
of  inebriety  and  its  social  consequences.  We  heard  many  witnesses  who  had  had 
every  sort  of  social  experience.  I  was  greatly  impressed  with  this  fact,  that  the 
opinion  of  the  public  in  this  matter  is  now  so  advanced  that  we  could  get  no 
witnesses  to  contest  the  thesis  that  the  principle  of  the  liberty  of  the  subject 
should  be  set  aside  when  we  have  to  deal  with  certain  forms  of  inebriety.  Even 
distinguished  witnesses  from  the  legal  profession,  whose  duty  it  is  to  protect  the 


MENTAL     DISEASES  321 

liberty  of  the  subject,  admitted  that  some  statutory  provisions  must  be  made  to 
control  persons  suffering  from  dipsomania  and  certain  kinds  of  inebriety.  Until 
the  legislature  finds  time  and  has  inclination  to  pass  such  measures,  the  prognosis 
of  such  diseases  is  mostly  hopeless.  The  exceptions  of  recovery  only  prove  the 
rule.  Those  exceptions,  in  my  experience,  apply  only  to  such  cases,  and  they 
are  very  few,  who  lose  the  drink  craving  at  about  the  age  of  thirty  or  so,  from 
some  sort  of  physiological  change  which  has  taken  place  in  their  brain  action  at 
that  time,  but  even  when  they  recover  they  are  not  usually  good  for  much  as 
citizens.  I  shall  speak  of  the  prognosis  of  alcoholism — an  entirely  different 
disease  from  dipsomania — later  on. 

The  forms  which  defective  inhibition,  insane  impulse,  and  explosive  conduct 
may  take  are  innumerable — destructiveness,  fire-raising,  satyriasis,  kleptomania, 
suicide,  homicide,  etc.  The  medico-legal  aspect  of  all  those  tendencies  is 
extremely  important,  and  we  must  sometimes  be  prepared  to  state  on  oath  in 
the  courts  our  views  of  prognosis  in  regard  to  them.     As  a  class  it  is  unfavourable. 

Conditions  of  Mental  Confusion  and  Stupor. — I  have  already  referred  to  the 
stuporose  conditions  as  sometimes  forming  a  part  of  the  sequence  of  clinical 
symptoms  in  melancholia,  but  there  are  conditions  of  stupor  and  confusion, 
not  associated  with  melancholia  or  mania,  that  form  of  themselves  a  symptoma- 
tological  group  of  mental  disease.  A  certain  amount  of  confusion  may  be  present 
in  almost  any  form  of  insanity,  but  it  may  also  exist  per  se.  Typical  cases  of 
stupor  are  characterized  by  negative  symptoms.  There  is  no  exhibition  of  active 
mind  at  all  present,  there  is  no  mental  reflex  as  the  result  of  any  mental  or  bodily 
excitant,  and  there  are  many  bodily  symptoms  which  show  that  the  higher 
brain  cells  are  almost  in  a  condition  of  suspended  function. 

There  are  certain  striking  bodily  symptoms  in  typical  cases  of  mental  stupor 
which  are  always  of  importance  in  prognosis.  The  circulation  is  very  disturbed, 
so  that  the  capillaries  have  lost  their  tone,  the  extremities  look  blue  and  feel 
cold,  the  whole  action  of  the  central  nervous  system  is,  to  a  certain  extent, 
lowered  and  devitalized,  the  ordinary  motor  reflexes  are  sometimes  almost 
abolished,  and  the  general  effect  is  very  alarming  to  the  non-medical  mind.  The 
relatives  think  that  a  person  in  such  condition  is  pretty  sure  to  die.  The  voluntary 
motor  system  is  found  to  be  in  three  conditions  in  different  cases  :  (i)  Passive 
and  unresistive  ('  anergic  '  stupor)  ;  (2)  Cataleptic,  with  a  decided  tendency  to 
keep  fixed  attitudes,  and  the  muscles  '  waxy  '  ;  (3)  Resistive,  so  that  a  strong 
resistance  is  made  to  change  of  positions,  to  walking,  etc.  Now  none  of  these 
necessarily  mean  a  bad  prognosis.  They  may  be  all  recovered  from  in  time  and 
with  proper  treatment.  Most  of  the  cases  of  stupor  occur  before  the  age  of  thirty. 
They  are  sometimes  mixed  up  with  hysterical  symptoms.  In  the  cataleptic  and 
non-resistive  condition  there  is  no  expression  of  the  face  or  eye  whatever.  In 
many  of  the  resistive  cases  there  is  a  marked  melancholic  expression.  It  has 
been  called  melancholia  attonita.  While  many  of  the  cases  result  from  purely 
bodily  causes  of  exhaustion,  many  of  them  are  also  the  result  of  terrible  mental 
shocks. 

A  few  of  the  cases  of  stupor  die,  in  spite  of  all  treatment,  of  exhaustion  and 
inanition.  As  a  group,  however,  they  recover  in  the  proportion  of  50  per  cent, 
but  there  is  an  unfortunate  tendency  in  about  30  per  cent  to  pass  into  dementia, 
and  those  Kraepelin  would  call  dementia  prcBcox  (see  p.  335).  Stupor  sometimes 
occurs  as  a  phase  in  cases  of  mania  or  melancholia  ;  and  at  the  end  of  a  pro- 
longed attack  of  acute  mania,  in  a  young  person,  there  may  be  a  stage  of 
stupor  which  may  closely  imitate  true  incurable  dementia.  One  must  be 
careful  not  to  give  an  unfavourable  prognosis  in  such  cases. 

Some   authors   use   the   term  '  primary  dementia  '  to  describe  certain  cases 

21 


322  INDEX     OF     PROGNOSIS 

of  stupor.  I  altogether  object  to  the  use  of  the  term  '  dementia  '  except  to 
describe  incurable  conditions  of  mental  enfeeblement.  It  is  also  sometimes 
called  '  confusional  insanity,'  but  confusion  requires  to  be  present  in  an  extreme 
degree  for  it  to  be  called  stupor,  although  psychologically  and  physiologically 
the  two  conditions  have  a  close  relationship,  and  the  one  may  be  simply  an 
aggravated  degree  of  the  other.  In  some  few  cases  of  stupor  we  may  have  sudden, 
automatic,  causeless  impulses  or  explosions,  like  a  mental  epilepsy.  Such 
symptoms  do  not  necessarily  indicate  a  bad  prognosis. 

States  of  Mental  Enfeeblement.  Dementia.  —  While  the  term  '  mental 
enfeeblement '  may  be  used  in  a  semi  -  popular  sense,  the  term  '  dementia  ' 
should  only  be  applied  to  a  condition  of  weakness  of  mind  in  regard  to  memory, 
power  of  attention,  interest  in  the  outside  world,  power  of  reasoning  and  of 
emotion,  these  in  by  far  the  larger  number  of  cases  occurring  as  a  secondary 
condition  to  some  more  or  less  acute  form  of  mental  disease.  Mental  exaltations, 
especially  acute  mania,  are  the  most  common  preludes  to  a  condition  of  dementia, 
but  there  are  a  \ery  few  cases  where  a  slow,  progressive  enfeeblement  occurs  in 
young  people,  just  as  senile  dotage  slowly  draws  on  as  a  physiological  process. 
Formerly  we  were  apt  to  think  that  the  cell- damage,  caused  by  toxins,  and  in 
acute  mania,  produced  a  state  of  damage  in  those  cells  with  a  tendency  to  atrophy ; 
but  further  study  of  the  subject  has  shown  that  the  primary  state  of  morbid 
exaltation  and  the  secondary  condition  of  mental  deterioration  and  ceU-death 
are  really  parts  of  the  same  process  and  are  the  result  of  a  possible  toxaemia  with 
a  strong  hereditary  tendency  towards  mental  disease.  We  find  that  by  far  the 
greater  number  of  cases  of  dementia  occur  as  a  sequel  to  and  a  part  of  adolescent 
insanity,  occurring  before  the  age  of  twenty-five.  I  have  sometimes  called  it 
a  '  postponed  imbecility.' 

Unfortunately,  in  secondary  dementia  the  prognosis  is  always  bad.  The 
patient  in  fact  cannot  recover,  because  50  per  cent  of  the  higher  brain  cells  in 
the  higher  and  anterior  parts  of  the  cortex  have  undergone  a  process  of  atrophy 
or  degeneration,  as  can  now  be  demonstrated  microscopically.  Dements  may 
live  for  a  long  time,  in  the  less  marked  cases  even  to  an  extreme  old  age,  but 
there  is  always  a  tendency  for  them  to  be  unduly  unresistive  to  the  ordinary 
causes  of  disease  and  death.  In  the  older  mental  hospitals,  where  there  was 
overcrowding  and  imperfect  ventilation,  and  where  the  diet  was  not  as  carefuUy 
attended  to  as  it  is  now,  30  per  cent  used  to  die  of  phthisis  pulmonalis.  In  many 
cases  of  secondary  dementia  the  '  stigmata  of  degeneration,'  to  which  I  shall 
presently'  allude  as  being  present  in  congenital  enfeeblement,  are  found. 

Conditions  of  Congenital  Mental  Weakness.  Amentia. — In  the  process  of 
growth  and  development  of  the  brain  there  is  liable  to  occur  an  arrest,  either 
in  utero,  or  in  the  first  five  years  of  life.  This  results  in  a  mental  enfeeblement, 
a.n  incapacity  for  education,  and  most  frequently  also  in  changes  from  the  normal 
appearance,  strength,  and  power  of  the  body  generally,  or  of  some  of  its  chief 
organs.  Of  recent  years  these  conditions  have  attracted  great  social  attention, 
and  have  been  subject  to  an  inquiry  by  a  Royal  Commission,  as  previously 
stated.  By  scientific  observers,  conditions  of  idiocy  and  congenital  mental  defect 
have  been  classified  in  various  elaborate  ways,  etiologically,  symptomatologically, 
and  pathologically.  Several  observers,  especially  of  the  Italian  school,  have 
been  inclined  to  put  down  a  considerable  proportion  of  them  to  ante-natal  toxic 
conditions.  This,  though  undoubtedly  applying  to  some  of  them,  has  not  yet 
been  proved  to  be  their  cause  in  by  far  the  majority  of  cases.  The  Royal 
Commission  to  which  I  have  referred  classified  them  into  : — 

I.  Idiots,  i.e.,  persons  so  deeply  defective  in  mind  from  birth,  or  from  an  early 
age,  that  they  are  unable  to  guard  themselves  from  common  physical  dangers. 


MENTAL     DISEASES  323 

such  as,  in  the  case  of  young  children,  would  prevent  their  parents  from  leaving 
them  alone. 

2.  Imbeciles,  i.e.,  persons  who  are  capable  of  guarding  themselves  from  common 
physical  dangers,  but  who  are  incapable  of  earning  their  own  Uving  by  reason  of 
mental  defect  existing  from  birth  or  from  an  early  age. 

3.  The  Feeble-minded,  i.e.,  persons  who  may  be  capable  of  earning  a  living 
under  favourable  circumstances,  but  are  incapable,  from  mental  defect  existing 
from  birth,  or  from  an  early  age,  {a)  of  competing  on  equal  terms  with  their 
normal  fellows,  or  [b)  of  managing  themselves  and  their  affairs  with  ordinary 
prudence. 

They  add  a  fourth  class,  moral  imbeciles,  the  class  of  which  I  have  already 
spoken. 

This  classification  is,  as  will  be  readily  seen,  largely  founded  on  administrative 
grounds,  for  the  purpose  of  enabling  the  legislature  to  adopt  different  measures 
and  to  provide  different  kinds  of  institutions  for  those  classes  of  defectives. 

Looking  at  the  whole  class  from  a  prognostic  point  of  view,  it  may  be  said  that 
they  are  all  incurable.  Idiocy  is  not  only  incurable,  but  is  only  improvable  to 
a  limited  extent,  in  regard  to  the  habits  and  ways  of  the  patients,  by  placing 
them  in  institutions  and  by  special  treatment.  Their  lives  may  thus  be  rendered 
somewhat  more  human  than  if  left  alone,  and  undoubtedly  may  be  prolonged. 
As  showing  the  fact  that,  in  this  condition,  not  only  the  brain  and  mind  are 
defective,  but  the  whole  nutrition  of  the  body  is  weakened,  it  is  found  that 
about  two-thirds  of  all  the  idiots  are  subject  to,  or  die  of,  tuberculous  disease. 
The  second  class,  of  '  imbeciles,'  are  educable,  in  special  institutions  and  by 
special  means,  to  a  considerable  extent ;  but  there  is  a  limit  to  this,  and  all  their 
lives  they  will  require  to  be  cared  for  by  others.  It  is  now  proposed  to  provide 
special  institutions  for  such  care  at  the  public  expense,  as  a  great  philan- 
thropic measure,  for  all  of  them  who  have  not  means  to  provide  such  care  for 
themselves.  Undoubtedly,  the  imbecile  may  be  enabled  to  lead  a  happier  life 
and  to  live  longer  through  such  special  care.  The  third  class,  of  the  '  feeble 
minded.'  often  called  'defectives,'  have  attracted  more  public  interest  than  the 
other  two  classes,  because  they  are  nearer  ordinary  humanity,  and  some  of  them 
exhibit  special  capacities,  e.g.,  in  music  and  mechanical  work,  etc.,  in  a  stronger 
degree  than  even  average  humanity.  There  is  a  great  social  and  eugenic 
question  connected  with  this  class  also,  namely,  the  risk  of  their  propagation,  the 
liability  of  some  of  the  female  defectives  to  fall  into  the  ranks  of  prostitution, 
and  other  social  and  moral  risks  to  which  society  is  liable  through  their  existence. 
The  educability  of  many  of  them,  during  childhood  and  youth,  is  such,  that  a 
few  may  be  made  self-supporting  members  of  society,  but  always  need  some 
supervision.  None  of  them  can  ever  attain  the  position  of  a  responsible  citizen 
The  whole  question  of  prognosis  is  mixed  up,  in  conditions  of  congenital  en-' 
feeblement,  with  legislative,  social,  and  educative  measures  on  their  special 
behoof,  and  improvement  can  only  be  attained  at  the  best  in  the  great 
majority  of  cases.  The  few  cases  which  are  really  restored  to  mental  capacity 
are  those  resulting  from  gross  pathological  conditions,  capable  of  recovery 
and  cure,  like  hydrocephalus  and  traumatic  injury  to  the  brain. 

Stigmata  of  Degeneration. — There  are  certain  kinds  of  bodily  and  mental 
abnormalities,  that  are  found  in  most  congenital  cases,  which  are  of  im- 
portance, both  in  diagnosis  and  in  prognosis.  These  have  been  called 
'  stigmata  of  degeneration.'  They  assume  innumerable  forms.  The  bones 
of  the  head  may  be  so  altered  that  they  make  it  abnormal  in  shape,  and 
so  alter  the  expression  of  face,  producing  the  effect  of  '  ugliness.'  Mal- 
formations of  the  hard  palate  are  the  most  frequent  of  all  the  bodily  stigmata. 


324  INDEX     OF     PROGNOSIS 

It  may  have  a  "  V  "  shape  or  a  saddle  shape,  or  it  may  be  cleft.  The  teeth  may 
alter  in  their  number  or  shape  or  disposition  ;  the  bones  of  the  thorax  may  be 
affected  so  that  we  have  pigeon-breast.  The  fingers  may  be  short  or  irregular  ; 
the  hand  may  be  of  that  shape  that  we  now  call  '  neurotic'  There  may  be 
supernumerary  fingers  or  toes  or  club-feet.  The  organs  of  special  sense,  especially 
the  eyes  and  the  external  ear,  may  be  abnormal ;  asymmetry  or  attached  lobes 
occur.  The  angle  of  the  eyelids  may  droop  so  as  to  produce  a  Mongolian  appear- 
ance. The  heart,  the  stomach,  the  bowels,  the  tongue,  the  genito-urinary 
system,  may  all  be  abnormal.  There  may  be  a  general  arrest  of  bodily  function 
producing  '  infantilism  '  and  dwarfishness.  The  general  power  of  expressing 
emotion  in  the  face  may  fail.  Certain  mental  stigmata  also  are  liable  to  appear. 
Arrested,  or  postponed,  or  unrelational  development  of  the  mental  faculties  is 
common.  Speech  may  be  defective  or  postponed  in  coming  on.  The  power  of 
reasoning  may  not  be  absent,  but  so  disturbed  that  the  victims  are  never  able  to 
draw  right  conclusions  from  premises,  however  obvious  they  may  be.  There 
are  cases  where  the  memory  is  so  prodigious  that  whole  pages  of  a  book  can  be 
repeated  after  once  reading  it.  Many  cases  of  an  abnormal  power  of  calculation 
are  on  record.  All  these  things  give  a  bad  prognosis  in  any  case.  They  are 
found,  but  not  so  frequently,  in  some  cases  of  adolescent  insanity,  and  are 
extremely  common  among  developmental  epileptics. 

Cretinism — Thyroid. — There  is  one  class  of  imbecile  children  where  the 
prognosis  is  not  always  unfavourable,  viz.,  the  cretins,  and  those  in  which  the 
thyroid  gland  is  affected  in  its  functions.  Many  of  these  are  either  cured  or 
markedly  benefited  by  the  administration  of  thyroid  gland.  Many  physicians 
now  try  thyroid  administration  experimentally  whenever  they  have  an  idiot 
or  imbecile  to  treat,  and  occasionally  great  improvement  is  thus  attained. 

General  Paralysis. — We  now  come  to  one  of  the  most  interesting  of  all  the  forms 
of  combined  brain  and  mental  disease — general  paralysis.  Its  prognosis  has 
this  profound  interest,  that  whUe  as  yet  there  is  an  almost  infinitesimal  record 
of  recovery,  there  is  a  strong  feeling,  founded  on  the  facts  of  its  etiology,  and 
of  the  results  of  recent  developments  in  vaccine  and  other  treatment,  that  its 
cure  will  become  possible  when  our  knowledge  in  regard  to  it  still  further 
increases,  and  that  it  may  be  prevented  by  an  early  cure  of  all  cases  of 
syphilis. 

The  chief  difficulty  in  this  disease  is  not  its  prognosis,  but  its  correct  diagnosis 
in  the  early  stages.  In  addition  to  the  well-known  clinical  symptoms  of  the 
disease,  the  Wassermann  reaction  has  now  taken  a  definite  place  as  perhaps 
the  most  important  of  all  in  confirmation  of  the  diagnosis.  The  disease  may  now 
be  said,  almost  definitely,  to  have  sjrphilis  as  its  predisposing  cause.  Whether 
there  is  not  another  and  proximate  cause  in  syphilized  subjects  to  account  for 
the  disease  is  as  yet  in  doubt.  Considering  that  it  only  occurs  in  from  2  to  4  per 
cent  of  those  who  have  acquired  syphilis,  and  that  it  is  not  amenable  to 
antisyphilitic  remedies,  it  seems  to  me  that  there  must  be  another  etiological 
element,  probably  in  the  shape  of  some  specific  micro-organism.  Dr.  Ford 
Robertson,  who  has  worked  long  and  arduously  at  this  subject,  is  of  this  opinion, 
and  he  believed,  at  one  time,  that  a  form  of  diphtheroid  organism,  wliich  he 
called  the  Bacillus  paralyticans,  was  the  proximate  cause  of  the  disease  ;  but 
this  has  not  as  yet  been  confirmed.  He  has  certainly  been  able  to  produce  a 
morbid  condition  of  the  brain  in  some  of  the  lower  animals  which,  in  symptoms 
and  pathological  appearance,  closely  resembles  the  disease,  by  using  injections 
of  cultivations  of  bacilli  from  general  paralytic  patients. 

The  duration  of  general  paralysis,  from  its  beginning,  varies  from  a  few  months 
to  over  twenty  years,  but  the  average  duration  of  life  is  a  little  under  three  years. 


MENTAL    DISEASES  325 

One  of  the  great  things  to  remember  in  general  paralysis  is  that  no  prognosis  is 
justifiable  until  the  disease  has  been  definitely  ascertained  to  exist.  Further, 
there  must  be  a  combination  of  mental  and  bodily  symptoms  present.  Certain 
mental  and  bodily  conditions  closely  resembling  general  paralysis,  produced  by 
alcohol,  syphilis,  epilepsy,  trauma,  organic  brain  disease,  acute  mania,  and 
chorea,  must  be  eliminated  before  any  diagnosis  or  prognosis  is  come  to. 

There  are  certain  symptoms  which  at  present  usually  mean  a  short  duration 
of  the  disease.  These  are  extreme  acuteness  of  symptoms  at  the  onset,  congestive 
attacks,  and  rapid  development  of  the  three  stages  one  after  the  other.  There 
are  other  symptoms  which  indicate  that  the  case  will  probably  last  long.  These 
are  a  slow,  insidious  onset  of  mental  enfeeblement,  freedom  from  maniacal 
symptoms  with  ambitious  delusions,  the  prolongation  of  the  first  stage,  and  the 
occurrence  of  what  appear  to  be  remissions  in  the  course  of  the  disease. 

We  now  recognize  that,  in  addition  to  the  classical  three  stages  of  the  disease, 
there  is  a  preliminary  or  prodromal  stage,  but  the  symptoms  of  this  are  as 
yet  so  uncertain  that  we  must  on  no  account  give  a  bad  prognosis  because 
of  any  such  apparent  prodromal  symptoms.  The  application  of  the  Wasser- 
mann  test  will,  however,  in  the  future,  help  us  greatly  in  regard  to  the  prognosis 
by  determining  the  character  of  such  preliminary  stages.  The  great  hope  for 
the  future  in  regard  to  general  paralysis  is  that  it  will  be  altogether  prevented 
by  the  early  cure  of  syphilis  in  all  cases. 

Syphilitic  Mental  Symptoms. — There  are  conditions  of  mental  disease  due  to 
the  direct  action  of  syphilis  on  the  brain,  its  neuroglia,  its  membranes,  or  its 
vessels,  apart  from  general  paralysis.  The  prognosis,  in  many  of  such  cases,  is 
exceedingly  good,  if  treated  in  time.  It  is  in  these  cases,  rather  than  in  general 
paralysis,  that  salvarsan  comes  in  as  a  mode  of  treatment,  and  the  Wassermann 
reaction  as  a  means  of  diagnosis.  If  mental  symptoms  occur  during  the  second 
stage  of  the  disease  they  are,  in  nearly  all  cases,  curable  under  the  proper  treat- 
ment of  the  disease.  These  secondary  mental  symptoms  are,  however,  very 
rare.  The  most  common  form  of  syphilitic  insanity  is  caused  by  various  forms 
of  vascular  disease.  Those  may  occur  in  any  degree.  Sometimes  they  are 
extremely  localized.  Usually  they  are  slow  in  their  course.  They  are  very 
difi&cult  to  diagnose  during  the  first,  which  is  undoubtedly  the  most  curable, 
stage.  If  we  have  marked  motor  paralysis,  indicating  serious  damage  to  the 
motor  centres,  the  symptoms  may  be  arrested,  but  we  can  seldom  hope  for 
cure.  In  such  cases  I  have  frequently  known  the  patient  recover  in  regard 
to  his  mental  condition,  but  still  remain  more  or  less  paralytic  and  live 
for  many  years.  The  occurrence  of  convulsions,  which  usually  take  the 
form  of  Jacksonian  epilepsy,  does  not  necessarily  indicate  a  bad  prognosis  if 
proper  treatment  is  adopted.  I  can  recall  a  case  where,  as  a  young  man, 
the  patient  had  both  slight  local  paralysis  and  Jacksonian  epilepsy,  but  who 
lived  for  fifty  years  and  did  good  work  during  most  of  that  time.  There  was  no 
progression  of  the  symptoms  in  his  case. 

There  is  a  form  of  what  I  believe  to  be  syphilitic  insanity  which  has,  at  first 
and  often  for  many  years,  no  bodily  symptoms  except  hallucinations  of  hearing, 
the  mental  symptoms  being  morbid  suspicions  and  tendencies  to  impulsive 
violence.  If  such  cases  are  diagnosed  and  treated  by  antisyphilitic  measures 
very  early,  I  have  seen  recovery  take  place  ;  but  if  really  established,  the  outlook 
is  very  hopeless  ;  it  becomes  an  ordinary  case  of  delusional  insanity.  Such 
cases  usually  have  a  bad  heredity,  and  the  syphilitic  brain  poisoning  seems  to 
light  up  this  heredity  into  actual  mental  disease,  just  as  an  excessive  use  of 
alcohol  might  have  done,  without  causing  very  marked  damage  that  can  be 
detected  microscopically  after  death. 


326  INDEX     OF     PROGNOSIS 

We  see  a  few  cases  of  acute  mental  disease  resulting  from  syphilitic  meningitis, 
from  gummata  causing  pressure  and  taking  the  form  of  local  convulsions  and 
acute  mania.  This,  if  detected  early  enough,  is  amenable  to  treatment  by  the 
iodides  in  very  large  doses.     The  risk  of  death  is,  however,  very  great. 

The  actual  number  of  cases  of  syphilitic  mental  disease  is  very  small,  in  my 
experience  being  only  one-half  per  cent  out  of  3145  cases  of  mental  disease 
altogether.  No  doubt,  in  minor  forms  treated  and  cured  out  of  institutions 
they  are  much  more  common,  and,  with  the  Wassermann  reaction  and  the  use  of 
salvarsan,  we  should  expect  syphilis  to  be  much  more  curable  and  free  from 
mental  complications. 

Alcoholism  and  Alcoholic  Mental  Disease. 

The  excessive  use  of  alcohol  is  statistically  the  most  frequent  cause  of  mental 
disease  in  this  country.  Its  incidence  ranges  between  6  to  25  per  cent  of  the 
cases  sent  to  institutions.  It  acts  both  as  a  predisposing,  exciting,  or  proximate 
cause  in  different  cases.  Alcoholic  mental  disease  takes  very  different  forms  in 
different  cases,  according  to  the  kinds  of  alcoholic  liquor  used  and  the  way  in 
which  it  has  been  taken.  Its  prognosis  may  in  different  cases  be  absolutely 
bad,  or  in  the  highest  degree  favourable.  Its  forms  and  characters  range  from 
acute  delirium  tremens  on  to  complete  dementia,  from  cases  where  its  bodily 
symptoms  are  the  most  important,  to  others  where  there  are  scarcely  any  bodily 
symptoms  present  at  all.  It  is  therefore  necessary,  in  considering  its  prognosis, 
to  take  its  forms  into  account.  I  find  that  out  of  the  11,346  cases  of  mental 
disease  sent  to  the  Royal  Edinburgh  Asylum  in  the  thirty  years  1874-1903,  there 
were  1644  cases  diagnosed  as  the  insanity  of  alcoholism.,  a  percentage  of  14-5  ; 
5540  cases  were  men  and  5806  were  women.  The  percentage  of  alcoholics 
among  the  men  was  i8-5  per  cent,  and  among  the  women  12-9  per  cent. 

Delirium  Tremens,  if  caused  by  the  stronger  liquors,  recovers  in  at  least  80  per 
cent  of  the  cases,  10  per  cent  dying,  and  other  10  per  cent  passing  into  the  more 
prolonged  insanities  with  hallucinations  and  a  doubtful  chance  of  recovery. 

It  is  now  stated  by  recent  authors  on  alcoholism,  like  Dr.  Hare,  that  delirium 
tremens  should  be  preventable  altogether  if  proper  measures  are  taken  when  it  is 
threatened  or  when  its  symptoms  first  appear.  Hare  calls  delirium  tremens 
an  '  abstinence  symptom,'  and  he  believes  Janregg's  theory  of  the  real  cause 
being  a  hypothetical  substance  called  an  '  anti-alcohol.'  He  strongly  advocates 
its  abortive  treatment.  This  is  carried  out  by  not  depriving  the  patient  of 
alcohol  suddenly,  and  giving  it  either  by  the  stomach  or  by  inhalation  with 
oxygen,  carrying  out  this  treatment  with  '  adequate '  quantities  until  the 
patient  begins  to  improve.  He  states  that  not  only  is  the  disease  better  treated, 
if  '  aborted  '  in  this  way,  but  the  risk  of  death  is  less,  and  the  risk  of  such 
complications  as  pneumonia  is  much  lessened.  I  should  like  to  see  the  term 
delirium  tremens  abolished  and  '  acute  alcoholism  '  substituted  for  it.  Patients 
not  only  recover  from  this  disease  but.  Hare  says,  there  is  little  risk  of  relapse, 
unless  alcohol  is  again  taken  to,  which,  most  unfortunately,  is  very  apt  to  be 
the  case.  When  the  temperature  falls,  and  the  power  of  sleep  is  restored,  the 
patient  may  be  pronounced  on  the  way  to  convalescence. 

Mania  a  Potu. — This  is  really  a  transitory  alcoholic  deUrium  to  which  patients 
of  a  certain  neurotic  type  of  brain  are  subject  from  a  bout  of  drinking,  or,  in  some 
cases,  from  even  small  quantities  of  alcohol.  It  does  not  imply  previous  alcoholic 
habit,  and  its  symptoms  almost  invariably  pass  off  in  a  few  days.  Its  occurrence 
means  that  the  patient  subject  to  it  should  never  taste  alcohol  in  any  shape  or 
form. 


MENTAL    DISEASES  327 


Chronic  Alcoholism. — When  we  pass  from  these  two  forms  of  alcohoHc  mental 
disturbance  to  chronic  alcohoUsm,  the  question  of  prognosis  worsens  in  a  very- 
marked  degree.  While  chronic  alcoholism  varies  in  most  of  its  symptoms, 
according  to  the  constitution  of  the  patient,  to  the  time  during  which  excessive 
alcohol  has  been  taken,  and  to  the  kind  of  liquor  used,  it  invariably  has  symptoms, 
bodily  and  mental,  of  a  much  graver  nature,  and  in  most  of  the  cases  there  are, 
after  death,  demonstrable  changes  in  the  brain  cells,  their  vessels,  neuroglia,  or 
envelopes.  In  most  cases  there  are  motor  symptoms,  these  taking,  in  some 
cases,  the  form  of  general  convulsions,  in  others  tremulousness,  sensory  symptoms, 
slow  motor  paralysis,  or  muscular  inco-ordination.  The  working  of  the  mind- 
muscles  in  the  face,  as  shown  by  the  facial  and  eye  expression,  is  invariably 
deteriorated  in  chronic  alcoholism.  Mentally,  the  patients  have  either  morbid 
suspicions  and  fears,  or  hallucinations  of  hearing.  There  is  always  also  moral 
deterioration,  loss  of  self-respect,  and  of  truthfulness  and  of  feelings  of  honour. 
The  memory  for  recent  events  is,  in  the  more  chronic  cases,  impaired.  There  is 
often  insomnia,  the  speech  is  often  blurred,  inco-ordinated,  or  thick.  The 
spinal  reflexes  are  often  abolished.  There  is  sometimes  peripheral  neuritis. 
The  patients  have  always  lost  some  of  their  inhibitory  power,  and  in  some  cases 
there  are  tendencies  both  to  suicide  and  homicide  as  well  as  to  other  morbidly 
impulsive  acts. 

As  to  the  prognosis  of  chronic  alcoholism,  it  is,  in  most  cases,  bad,  on  account 
of  the  organic  lesions  of  the  brain  to  which  I  have  referred,  and  the  fixed  and 
strong  habit  of  excessive  use  of  drink ;  but  in  my  experience  a  certain  number 
of  the  cases,  with  even  marked  symptoms,  get  better  if  properly  treated.  The 
length  of  time  the  patient  has  drunk  excessively,  and  the  duration  of  marked 
mental  symptoms,  are  the  two  circumstances  on  which  prognosis  must  chiefly 
depend.  If  the  patient  has  been  a  chronic  drunkard  for  many  years,  and  if  the 
mental  symptoms  are  comparatively  recent,  and  have  in  them  some  of  the 
characters  of  acute  alcoholism,  then  the  prognosis  may  not  be  absolutely  bad. 
I  have  seen  some  even  unfavourable  cases  improve  so  much  under  the  use  of 
iodide  treatment  that  they  were  no  longer  technically  insane ;  but,  in  most  of  the 
cases  who  thus  improve,  a  careful  psychological  analysis  of  the  patient's  mental 
and  moral  faculties,  and  especially  of  his  power  of  mental  inhibition,  will  show 
that  there  is  some  deterioration  as  compared  with  his  normal  condition.  There 
are  a  few  cases  in  which,  when  the  chief  symptoms  of  chronic  alcoholism  have 
disappeared,  there  also  disappears  the  craving  for  drink,  but  I  think  this  results 
more  from  a  certain  lowering  of  nervous  and  mental  action  than  from  a  recovery 
in  self-control.     Complete  recovery  is  usually  a  long  process  when  it  occurs. 

Alcoholic  Dementia  and  Degeneration. — Patients  who  have  taken  alcohol 
in  excess  for  many  years  are  liable  to  a  general  lowering  of  the  mental  condition, 
to  a  diminished  power  of  initiative  and  action,  and  especially  to  defects  of 
memory  that  are  very  characteristic.  The  expression  of  the  face  and  eyes 
are  altered  and  deteriorated,  and  the  man  is  not  at  all  '  the  same '  as  he  was. 
There  need  not  have  existed,  in  such  cases,  any  previous  form  of  acute 
alcoholism  or  insanity.  I  need  hardly  say  that  this  condition  is  entirely  hope- 
less in  regard  to  the  prognosis,  and  the  older  the  man  is,  the  worse  the  outlook. 
Such  a  condition  seems  to  bring  on  senile  dotage  prematurely.  The  brain 
cells  are  hopelessly  degenerated. 

'  Respectable  '  Excess.  —  To  anyone  accustomed  to  observe  carefully  the 
expression  of  the  face  and  the  intimate  psychology  of  some  of  his  friends  and 
acquaintances  who  take  much  liquor,  there  are  minor  mental  degenerations 
to  be  seen  as  the  result,  not  of  constant  drunkenness,  but  of  what  has  been 
really  excess  in  the  habitual  use  of  alcohol,  though  it  may  not  have  been  counted 


328  INDEX     OF     PROGNOSIS 

very  unusual.  They  were  respectable  drinkers.  The  finer  traits  of  mind  and 
character  get  lost.  There  is  a  coarsening  of  the  moral  tone,  a  lack  of  energy 
and  activity  in  life;  selfishness  and  egoism  are  seen  in  too  marked  a  degree. 
Now  in  the  very  beginning  of  this  condition,  if  a  man  has  judicious  friends 
and  a  firm  doctor,  so  that  he  is  persuaded  to  abandon  entirely  the  use  of  alcohol, 
to  take  a  great  deal  of  exercise,  and  resort  to  outdoor  games,  these  suspicious 
symptoms  may  entirely  disappear  and  the  man  may  become  his  old  self.  I 
have  seen  many  such  cases. 

I  have  already  treated  of  dipsomania  as  one  of  the  forms  of  defective  inhibi- 
tion. 

Morbid  Cravings  for  Various  Drugs. — Opium,  chloral,  cocaine,  and  various 
other  drugs  of  the  nerve-stimulant  or  nerve-sedative  type  may  be  taken  to 
such  excess  that  they  become  a  morbid  habit  and  virtually  forms  of  mental 
disease.  It  may  be  said  that  in  regard  to  most  of  them  the  habit  may  be  broken 
and  the  patient  cured,  for  the  time  being,  but  only  through  outside  control 
and  special  treatment.  The  patients  are  not  able,  of  their  own  accord,  to  cure 
themselves  and  abandon  those  drugs.  The  opium  habit  is  the  most  common, 
and  if  long  continued  is  more  liable  to  end  in  death  than  any  other,  through 
stomach  irritation  and  incapacity  to  receive  food.  My  experience,  however, 
is  that  the  cocaine  habit  is  really  the  most  difficult  to  break,  and  the  most  apt 
to  return.  Cocaine  is,  in  fact,  the  most  fascinating  and  the  most  powerful 
destroyer  of  human  inhibition  of  any  substance  known  to  us.  I  have  seen  a 
complete  cure  of  the  opium  habit  after  thirty  years'  duration.  I  have  never 
seen  a  cure  of  the  cocaine  habit  at  all.  Special  institution  treatment  is  necessary 
in  by  far  the  majority  of  cases  of  the  drug  habit,  though,  where  the  means 
allow,  a  doctor's  house  or  a  home  with  special  nursing  may  be  effectual. 

The  prognosis  in  the  opium  habit  depends  on  (i)  The  patient's  resolution 
to  undergo  treatment ;  (2)  His  response  to  treatment  in  its  early  stages. 
During  the  gradual  tapering  down  of  the  drug,  which  is  the  method  now  always 
practised,  there  is  intense  misery  and  prostration.  If  the  sickness,  diarrhoea, 
and  consequent  exhaustion  are  extreme,  the  patient  may  die,  or  the  treatment 
may  even,  in  a  few  cases,  have  to  be  stopped  to  save  his  life. 

The  Mental  Symptoms  of  Organic  Brain  Diseases. — When  we  have  attacks 
of  apoplexy  or  hemiplegia,  especially  in  advanced  life,  they  are  almost 
invariably  accompanied  by  mental  symptoms.  The  same  thing  occurs  as 
the  result  of  tumours,  atrophies,  and  many  gross  forms  of  brain  degeneration. 
Those  symptoms  sometimes  take  the  form  of  morbid  excitement,  but  in  essence 
they  are  an  enfeeblement  of  mind.  We  find,  in  a  large  number  of  such  cases, 
an  emotionalism,  a  childishness,  a  morbid  suspiciousness,  a  loss  of  will-power, 
a  diminished  power  of  work,  and  a  lessened  mental  energy.  These  symptoms 
do  not,  in  most  cases,  constitute  an  insanity  in  the  popular  sense.  The  mental 
symptoms  are  apt  to  be  more  acute  in  the  early  stages  of  most  organic  diseases, 
and  more  those  of  enfeeblement  in  the  later  stages,  especially  in  paralysis  with 
softening  of  the  brain.  If  we  have  an  embolism  of  one  of  the  smaller  brain 
arteries  in  a  young  person,  it  may  produce  local  paralysis  without  almost  any 
mental  symptoms  after  the  first  few  weeks,  and  the  same  is  seen  in  syphilitic 
vascular  disease.  Taking  the  statistics  of  the  Royal  Edinburgh  Mental  Hospital 
for  the  nine  years  1874-1882,  we  had,  out  of  3145  admissions,  91,  or  3  per  cent, 
of  this  kind  of  mental  disease,  which  means  that  the  mental  s^'mptoms  in  those 
were  of  a  marked  type.  Of  these  91  cases,  17,  or  almost  19  per  cent,  recovered. 
I  do  not  say  that  all  the  recoveries  were  so  perfect  that  the  subjects  of  them 
were    not   handicapped   in    some  way,    but    this   favourable   result,  I  confess. 


MENTAL    DISEASES  329 


surprised  me.  I  had  expected  a  considerably  less  '  recovery  '  rate.  The 
treatment  really  consists  in  proper  nursing  and  non-stimulating  diet,  and  if 
the  patient  improves  within  the  first  month,  his  chances  of  at  least  a  partial 
mental  recovery  are  good,  but  it  will  probably  be  slow.  The  patient's  age  is 
perhaps  the  most  important  thing  in  forming  the  prognosis.  If  his  age  is  great 
and  there  are  signs  of  arterial  degeneration,  it  is  bad. 

Epileptic  Unsoundness  of  Mind. — Epilepsy  is  unfortunately  associated  with 
mental  disturbances  or  mental  defect  in  a  very  large  proportion  of  cases.  Those 
disturbances  and  defects  assume  a  great  variety  of  forms,  and  their  degrees 
and  intensity  are  strikingly  different.  For  prognostic  purposes  we  have  to 
divide  epileptic  unsoundness  into  three  groups  :  (i)  Mental  defect  as  an 
almost  universal  accompaniment  of  the  disease  when  it  occurs  before  seven 
years  of  age  ;  (2)  Mental  defects  and  disturbances,  when  they  arise  during 
the  developmental  period  between  seven  and  twenty-five  years  of  age,  the 
largest  number  of  cases  occurring  during  this  period,  and  the  most  typical 
mental  effects  being  then  seen  ;  (3)  Epilepsy  occurring  in  the  fully  developed 
and  senile  periods. 

The  defects  in  the  first  period  are  those  of  mental  deficiency  from  a  retarded 
development  of  brain,  and  the  prognosis  is  the  same  as  in  idiocy  and  imbecility. 
It  may  be  said  to  be  hopeless  if  the  fits  are  frequent  and  regular  in  course,  but 
there  are  a  few  cases  of  convulsions  of  the  infrequent  and  sporadic  character, 
at  that  period  of  life,  in  whom  the  brain  and  mental  development  is  not  very 
seriously  arrested  or  retarded.  The  epilepsy  of  this  period  of  life  is,  in  most 
cases,  accompanied  by  such  abnormalities  and  stigmata  as  I  have  described 
in  idiocy.  We  look  on  the  mental  defects,  the  bodily  stigmata,  and  the  fits, 
as  being  all  effects  of  the  common  factor  of  arrest  in  brain  growth  and  develop- 
ment. As  a  matter  of  fact,  however,  the  occurrence  of  epilepsy  is  a  very 
unfavourable  factor  as  regards  educability  and  improvement  in  the  mental 
condition,  either  when  carried  out  in  the  form  of  special  training  in  institutions 
or  at  home.  Any  improvement  thus  produced  is  apt  to  be  arrested  and  put 
back  by  the  frequent  occurrence  of  the  fits. 

The  second  form  of  epilepsy  may  be  consistent  with  technical  soundness 
of  mind  between  the  fits,  especially  during  the  earlier  part  of  the  disease,  but 
the  general  tendency  is  towards  mental  deterioration  when  it  is  long  continued, 
and  there  is  always  a  danger  of  the  occurrence  of  conditions  of  mania,  often  of 
a  very  severe  type,  and  of  delusional  conditions  connected  with  the  fits.  The 
prognosis  is  not  absolutely  bad,  for  there  are  men  and  women  who  have  occasional 
sporadic  fits  during  many  years,  or  during  the  whole  life-time,  without  the 
occurrence  of  technical  insanity  or  even  marked  mental  deterioration.  Efficient 
work  in  life  may  be  done  in  those  cases,  but  a  careful  observation  of  the 
character  and  whole  life-history  of  the  epileptic  who  is  reckoned  sane,  is  apt 
to  result  in  the  conclusion  that  even  in  them  there  are  apt  to  be  slight  abnor- 
malities in  the  emotions  and  character.  The  occurrence  of  epileptic  fits  at 
very  rare  intervals  may,  however,  be  compatible  with  great  mental  power, 
and  even  with  genius.  It  is  usually  said,  but  the  statement  lacks  definite 
scientific  proof,  that  Julius  Caesar,  Mahomet,  and  Napoleon  were  subject  to 
such  attacks. 

The  mental  symptoms  in  ordinary  epilepsy  usually  occur  after  one  or  more 
fits.  In  such  cases,  the  symptoms  are  acute  and  often  extremely  violent, 
sometimes  with  attempts  at  homicide.  The  epileptic  maniac  is  an  extremely 
dangerous  man.  These  acute  mental  symptoms  commonly  occur  within 
twenty-four  hours  of  the  convulsions.  There  are  many  epileptics  who  are 
subject  to  mental  disturbances  as  a  prelude  to  the  fits.     These  show  themselves 


330  INDEX     OF     PROGNOSIS 


a  day  or  two  before  the  convulsions  occur,  and,  in  many  cases,  the  mental 
symptoms  cease,  apparently  as  the  result  of  the  fit.  There  are  a  few  cases 
where  a  mental  disturbance  will,  as  it  were,  take  the  place  of  the  fits ;  this  is 
the  mental  epilepsy,  the  false  consciousness,  the  epilepsia  larvee  of  the  French. 
If  epilepsy  persists  year  by  year  there  is  almost  always  a  mental  deterioration, 
a  loss  of  memory,  a  change  of  affection,  a  blunting  of  the  finer  feelings,  a  morbid 
egoism  and  selfishness,  all  these  symptoms  getting  worse  as  time  goes  on.  This 
is,  in  fact,  an  epileptic  dementia.  The  prognosis  in  this  second  class  of  epileptics 
is  extremely  bad  in  regard  to  complete  recovery.  Attention  to  the  health 
and  diet,  abstinence  from  alcohol,  a  routine  life  of  work  in  the  fresh  air,  and 
a  steady  use  of  the  bromides,  in  suitable  cases,  will  undoubtedly,  in  most  cases, 
result  in  a  diminution  in  the  number  of  attacks  and  in  an  enormous  modification, 
for  the  better,  of  the  acuter  mental  symptoms.  I  used  to  have,  in  the  Ro3'al 
Edinburgh  Asylum,  a  steady  average  of  thirteen  epileptics  sent  to  the  institution 
every  year,  and  of  about  forty  constant  residents,  and  after  I  put  the  greater 
number  of  them  on  constant  doses  of  from  25  to  50  gr.  of  bromide  of  potassium 
every  twenty-four  hours,  the  acuter  forms  of  epileptic  mania  practically 
ceased,  and  I  was  able,  in  ten  years,  out  of  115  admissions,  to  discharge  22, 
or  19  p3r  cent,  as  '  recovered  '  mentally.  This  gives,  however,  too  favourable 
a  prognostic  result,  because,  if  the  patient  who  has  been  certified  as  insane  in 
an  institution  remains  mentally  free  from  technical  insanity  for  twelve  months, 
although  he  is  still  an  epileptic  and  subject  to  mental  attacks,  we  must  legally 
discharge  him  as  recovered  from  his  mental  disease,  and  many  of  these  recoveries 
were  contingent  on  their  regularly  using  the  bromides,  which,  by  the  way, 
it  is  extremely  difficult  to  get  carried  out  when  a  patient  feels  himself  pretty 
well  and  does  not  have  the  fits  for  a  certain  time.  Statistics  show  that  51  per 
cent  of  all  epilepsy  comes  on  before  fourteen  years  of  age,  and  95  per  cent  before 
twenty-five.  This  fact  clearly  shows  its  definite  relationship  to  the  early  period 
of  life  and  brain  development.  The  Royal  Commission  to  which  I  have  alluded 
gives  some  statistics  in  regard  to  epilepsy.  It  quotes  one  estimate  as  being 
one  sane  epileptic  per  thousand  of  the  population.  This  would  make  the 
number  in  the  country  45,216,  but  another  investigator  gives  the  number  as 
only  19,516  for  England  and  Wales.  Such  a  discrepancy  shows  that 
these  estimates  are  unreliable.  The  estimate  of  the  Commissioners  in  regard 
to  insane  epileptics  in  asylums  and  workhouses,  or  in  the  general  population, 
is  that  their  number  amounts  to  one  in  ten  thousand,  or  4521.  As  an 
actual  matter  of  fact  there  are  11,078  epileptics  out  of  an  insane  popu- 
lation in  the  county  and  borough  asylums  of  England.  My  estimate  is  that 
there  are  100,000  epileptics,  sane  and  insane,  in  Great  Britain  and  Ireland. 
The  prevalence  of  epilepsy  in  difierent  counties  and  districts  of  England 
differs  enormously.  It  may  be  said  that  in  those  agricultural  counties  of  Eng- 
land which  are  largely  beer-  or  cider-drinking,  the  proportion  of  epileptics 
in  the  mental  hospitals  is  much  greater  than  in  the  manufacturing  counties 
and  large  cities,  and  amounts  to  11  per  cent  of  aU  the  admissions  to  county 
asylums.  In  the  large  cities  of  England  they  amount  to  8  per  cent,  and  in 
Scotland  to  about  4  per  cent  of  the  admissions.  It  is  a  curious  fact,  as  illus- 
trating the  possibility  of  treating  epileptics  and  epileptic  insanity  at  home, 
and  in  private  houses,  where  there  are  sufficient  means,  that  the  proportion 
of  epileptics  among  private  patients  in  mental  hospitals  is  enormously  less 
than  among  the  rate-paid  class  of  insane. 

In  regard  to  the  third  class  of  epileptic  insane,  where  the  disease  has  come  on 
after  twenty-five  years  of  age,  which  amounts  to  5  per  cent  of  the  total  number, 
it  is,  to  a  large  extent,  the  result  of  excessive  alcohol  or  traumatism  or  vascular 


MENTAL    DISEASES  331 

disease  in  old  age.  The  prognosis  in  many  such  cases  is  more  favourable  than 
in  the  cases  that  have  occurred  before  twentj^-five.  I  have  no  actual  statistics, 
but  I  would  give  it  at  about  30  per  cent  if  treatment  has  been  begun  at  once. 
In  dealing  with  the  prognosis  of  epileptic  mental  disease  one  must  not  leave 
out  of  account  the  fact  that  most  epileptics  are  exceedingly  apt  to  have  an  uncon- 
trollable craving  for  alcohol,  and  that,  under  the  influence  of  alcohol,  they 
become  far  more  dangerous  and  homicidal.  It  is  well  known  that,  of  the  number 
of  homicides  committed  in  the  country,  a  certain  proportion  of  the  murderers 
are  epileptics.  Any  medical  man  having  an  epileptic  to  treat  should  certainly 
point  out  this  note  of  possible  danger  in  every  case. 

Mental  Diseases  Associated  with  Childbirth. 

The  mental  affections  connected  with  childbirth  have  been  naturally  assorted 
into  those  which  are  liable  to  occur  during  pregnancy,  those  which  occur  soon 
after,  and  as  the  result  of,  confinement,  and  those  that  occur  during  nursing.  By 
far  the  most  important  and  the  most  frequent  of  these  is  puerperal  insanity,  which 
term  is  somewhat  artificially  restricted  to  apply  to  cases  occurring  within  the  first 
six  weeks  after  delivery.  This  does  not  present  the  same  symptoms  in  all  the 
cases,  but  the  larger  number  and,  as  it  were,  the  general  type,  consists  of  those 
occurring  within  the  first  fortnight  after  delivery.  This  type  is  about  the  acutest 
form  of  mental  disease  ever  met  with,  and  the  m.ost  deadly,  always  excepting 
general  paralysis.  The  temperature  is  high,  rising  sometimes  to  106°.  The  pulse 
is  extremely  weak  and  thready,  the  patient  looks  extremely  exhausted,  the  lochia 
cease,  the  mucous  membranes  are  apt  to  be  dry,  the  eyes  are  brilliant,  and  the 
bodily  condition  is  one  of  great  exhaustion  and  obvious  risk.  The  mental 
symptoms  are  of  the  acutest  type.  The  attention  cannot  be  fixed,  the  patient 
is  in  a  condition  approaching  delirium.  She  takes  no  notice  of,  and  has  no 
interest  in,  her  baby  ;  she  gets  violent  and  may  have  to  be  held  in  bed ;  she  will 
not  take  food ;  and,  above  all,  we  have  the  gravest  symptom  that  can  occur  in 
mental  disease,  she  may  try  to  injure  her  baby  or  put  an  end  to  her  own  life. 
Now  this  condition  resembles  a  toxaemia  so  closely  that  it  is  difficult  to  believe 
it  is  not  of  that  character ;  but  no  specific  organism  has  been  yet  detected, 
though  diphtheroid  and  other  micro-organisms  have  been  found,  especially  in  the 
urine,  but  some  recent  authors  deny  its  toxic  character.  Looking  at  it  from  a 
clinical  point  of  view,  such  acute  cases  certainly  seem  the  result  of  some  toxic 
poison.  Their  prognosis  in  regard  to  recovery  is  extremely  good.  They  not  only 
recover  quickly,  most  of  them  within  three  months,  but  the  recovery  is  a  complete 
one,  not  subject  to  relapse.  But  there  is  one  distinct  risk  in  such  acute  cases, 
and  that  is  of  death,  especially  when  the  temperature  goes  much  above  102°. 
The  death-rate  in  these  amounts  to  over  10  per  cent.  My  experience  is  that 
the  test  of  the  risk  of  death  is  found  in  the  temperature  above  all  other  symptoms. 
I  have  found  that  over  80  per  cent  of  such  acute  cases  recover.  They  are 
subject  to  intercurrent  diseases — septic  inflammation  of  the  womb  and  its 
surroundings,  meningeal  inflammation,  and  incidentally  mammary  abscess. 
As  might  have  been  expected,  heredity  comes  in  as  a  predisposing  cause  of 
mental  disease  after  confinement,  as  it  does  in  most  other  cases. 

There  is  a  type  of  puerperal  mental  disease  of  a  milder  type  than  that  which 
I  have  described,  constituting  about  one-half  of  the  cases.  In  these,  the  sym- 
ptoms are  all  milder,  without  much  tendency  to  an  abnormally  high  temperature, 
and  with  the  risk  of  death  greatly  diminished.  These  recover  in  the  proportion 
of  about  70  per  cent,  some  of  them  running  on  into  chronic  insanity  and 
dementia.  They  do  not  recover  quite  so  quickly  as  the  very  acute  cases  of  the 
disease,  taking  sometimes  six  months  to  get  better ;  but  in  the  milder,  as  in  the 


332  INDEX     OF     PROGNOSIS 

acuter  cases,  the  risk  of  the  mother  injuring  the  child  has  to  be  kept  in  mind 
in  every  case,  and  the  nurses  and  relations  must  be  seriously  warned  on  that 
point. 

Lactational  Insanity. — When  a  woman,  in  addition  to  having  a  child,  fulfils 
the  natural  duty  of  nursing  it,  and  she  is  perhaps  not  strong  in  general  health, 
and  in  poor  circumstances  implying  hard  work  and  insufficient  nourishment,  she 
may,  if  there  is  any  innate  liability  to  the  neuroses  or  to  insanity,  become 
affected  in  mind  during  such  nursing.  We  call  this  '  lactational  insanity.'  It 
is  apt  to  be  an  anaemic  disease  attended  by  exhaustion  of  body  and  depression 
of  mind.  The  mental  symptoms  are  usually  preceded  by  headaches,  flashes  of 
light,  feelings  of  exhaustion,  and  irritability.  If  these  are  seen  and  treated  in 
time,  the  chances  are  that  no  mental  symptoms  will  supervene.  When  they 
do  appear,  the  risk  of  suicide  should  be  kept  in  mind.  In  some  cases  the 
symptoms  are  those  of  mania.  My  experience  is  that  over  77  per  cent  of  the 
lactational  cases  recover,  but  the  recovery  takes  a  longer  time  than  in  the 
puerperal  cases,  because  the  general  strength  has  run  down  to  a  greater  degree. 
Lactational  insanity  seldom  occurs  among  the  better-off  classes,  the  reason  being, 
no  doubt,  that  they  have  proper  nourishment  and  are  not  being  over-worked 
while  they  are  nursing  their  children.  With  proper  nursing  and  good  food  we 
should  not  lose  a  lactational  case.  Most  of  them  respond  to  such  treatment 
at  once. 

The  Mental  Disturbances  of  Pregnancy. — This  is  a  rare  form  of  mental  disease. 
The  symptoms  are  usually  mild  depression,  but  there  is  always  a  risk  of  this 
depression  leading  to  suicide.  Most  cases  of  the  mental  disease  of  pregnancy 
have  a  bad  neurotic  heredity.  The  worst  class  of  cases,  those  sent  to  mental 
hospitals,  only  recover  in  the  proportion  of  60  per  cent,  and  of  those  who  do 
not  recover,  a  large  number  pass  rapidly  into  dementia.  Women  are  more 
liable  to  have  mental  symptoms  during  the  first  than  subsequent  pregnancies, 
especially  if  they  are  over  thirty-five.  As  a  question  of  prognosis,  the  treat- 
ment of  serious  mental  symptoms,  occurring  during  early  pregnancy,  by  abortion 
or  premature  labour,  is  now  a  measure  to  be  seriously  faced  by  the  medical 
man.  For  myself,  I  am  of  opinion  that  this  should  be  done  after  consulting 
with  another  medical  man,  and  with  the  full  written  consent  of  the  husband  or 
nearest  relation.  It  gives  a  better  chance  to  the  mother,  which  is  the  first 
consideration,  and  it  prevents  the  entrance  into  the  world  of  a  human  being 
who  would  be  extremely  liable  to  be  mentally  affected.  Dr.  Routh  describes 
the  '  Toxaemias  of  Pregnancy.'  No  doubt  these,  in  predisposed  subjects, 
account  for  some  of  the  insanities. 

The  mental  disturbances  connected  with  childbirth  occur  in  the  proportion 
of  5  per  cent  puerperal,  4  per  cent  lactational,  and  i  per  cent  pregnancy,  in 
Edinburgh.  In  Cumberland  and  Westmorland  my  experiences  for  the  ten 
years  1863-73  is  that  they  occurred  in  the  proportion  of  17J  per  cent  of  all  the 
female  cases.  When  they  recover  they  remain  well  mentally  with  very  small 
chance  of  relapse,  except  those  who  have  subsequent  childbirths. 

The    Epochal    Mental    Disturbances. 

In  addition  to  the  mental  disorders  of  which  I  have  spoken,  connected  with 
childbirth,  certain  other  epochs  of  life  are  subject  to  mental  disturbances  of 
a  somewhat  characteristic  kind,  with  many  distinctive  symptoms  and  marked 
differences  in  their  prognosis.  In  the  ordinary  man  and  woman,  with  a  reasonably 
good  heredity,  the  various  eras  and  epochs  of  life  are  passed  through  without 
much  risk  of  mental  upset.  It  is  different  with  those  of  the  neurotic  and  psycho- 
pathic   constitution.     The    physiological    characteristics    are,    in    them,    more 


MENTAL     DISEASES  333 


liable  to  pass  into  pathological  states.  Each  era  of  life  has  its  own  normal 
psychology,  and  the  passing  from  one  into  the  other  may  quite  naturally  be 
expected  to  have  some  influence  on  the  mental  working.  The  epochal  psychoses 
will  always  be  co-related  to  the  epochal  neuroses  by  the  thoughtful  physician, 
and  we  know  that  the  '  critical  '  periods  of  life  are  often  attended  with  nervous 
as  well  as  mental  symptoms. 

Childhood,  Boyhood  and  Girlhood.^This  era  has  a  singularly  characteristic 
psychology,  and  is  very  free  from  such  mental  disturbances  as  can  be  rightly 
called  insanitJ^  When  such  disturbances  are  seen  they  usually  take  the  form 
of  short  attacks  of  maniacal  elevation  resembling  delirium,  which  soon  pass  off, 
but  may  recur  a  few  times  before  final  recovery.  A  very  few  indeed  have  attacks 
of  depression  of  mind  which  are  apt  to  be  recurrent.  There  are  some  children, 
always  those  of  the  neurotic  diathesis,  who,  whenever  they  become  feverish 
from  any  cause,  are  extremely  liable  to  become  delirious.  Even  temperatures 
under  100°  may  cause  severe  delirium  in  them.  It  may  be  said  that  the  mental 
disturbances  of  children,  except  those  in  the  very  early  periods  of  life  which 
are  either  syphilitic  or  of  the  nature  of  idiocy  and  other  mental  arrestments,  are 
curable,  and  are  speedily  recovered  from.  Left  to  nature,  or  with  the  use  of 
mild  sedatives  such  as  the  bromide  of  ammonium,  they  speedily  return  to 
their  normal  state. 

Puberty  and  Adolescent  Mental  Disturbances. — The  great  physiological  and 
mental  changes  that  take  place  at  puberty  and  go  on  for  ten  years,  through  the 
period  of  adolescence,  are  attended  with  more  serious  mental  and  nervous  risks 
than  any  of  the  epochs  of  life,  except  childbirth.  It  is  unfortunately  true  that 
the  prognosis  is  very  serious  in  many  of  those  cases.  At  least  30  per  cent  of 
the  mental  cases  ultimately  fall  into  that  state  of  mental  deterioration  and 
death  which  I  have  described  under  dementia  and  dementia  prascox. 

The  chief  and  the  most  characteristic  phases  of  the  mental  disturbances  at 
puberty,  and  more  especially  during  adolescence,  are  a  tendency  to  attacks  of 
naaniacal  excitement,  often  very  acute  in  character,  each  individual  attack  not 
lasting  long,  and  when  it  abates,  recovery  seeming  to  have  taken  place.  But 
those  attacks  have  a  tendency  to  return,  often  many  times ;  in  fact,  adolescent 
insanity,  as  I  have  called  it,  is  especially  a  periodic  and  recurrent  form.  In 
forming  a  prognosis  of  this  form  of  mental  disturbance  it  is,  in  the  first  place, 
necessary  to  observe  whether  the  patient  is  averagely  developed  and  has  no 
bodily  stigmata  of  degeneration.  These,  unquestionably,  may  be  bad  signs  in 
regard  to  recovery.  If,  in  addition,  he  has  been  somewhat  backward  in  mental 
development  or  prone  to  undue  excitability,  or  has  shown  defects  in  morals 
and  character  in  a  marked  degree,  if  he  has  been  '  thoughtless  '  and  not  very 
educable,  then  the  outlook  is  not  very  good,  but  not  necessarily  very  bad. 
Even  cases  with  such  characters  recover  in  many  instances.  If,  on  the  contrary, 
he  has  been  well  developed  and  normal  up  to  the  time  of  the  attack,  in  body 
and  mind,  if  the  attack  has  been  of  manic-depressive  character,  and  if,  after  the 
first,  we  notice  that  the  subsequent  attacks  are  less  acute  and  shorter  in 
duration,  we  are  entitled  to  form  a  favourable  prognosis.  As  a  matter  of  fact, 
mental  disease  of  marked  character  does  not  occur  so  frequently  until  a  later 
period  of  adolescence,  namely  from  seventeen  to  twenty-five.  I  have  always 
held  and  thought  that  the  liability  to  such  attacks  was  coincident,  in  persons 
with  a  bad  heredity,  with,  not  the  actual  gain  in  weight  of  the  brain,  which  has 
virtually  ceased  before  that  time,  but  with  its  development  in  its  highest  function 
of  mentalization.  One  need  not  be  a  physiologist  or  a  psychologist  to  realize 
how  momentous,  during  this  time  of  life,  are  the  subtle  changes  in  brain  working 
which  mean  full  reasoning  power,  large  powers  of  self-control  and  moral  feeling, 


334  INDEX     OF     PROGNOSIS 

development  in  a  normal  form  of  the  religious  instincts,  proper  regulation  of 
sex  feelings,  appreciation  of  the  higher  forms  of  literature,  and  manliness  and 
womanliness  of  the  best  type.  All  these  have  not  usually  come  to  perfection 
at  the  age  of  seventeen  ;  they  are,  or  should  be,  by  twenty-five.  A  moment's 
consideration  shows  that  in  the  formation  of  a  brain  vehicle  for  these  qualities, 
so  momentous  to  a  successful  life,  a  certain  strain  is  put  on  the  organ  and  its 
higher  cells.  Now  the  period  of  this  strain  is  the  period  of  liability  to  adolescent 
insanity.  If  one  closely  notices  the  bodily  developments  at  this  time  of  life, 
we  see  marked  changes  in  the  direction  of  attaining  the  mental  and  bodily  ideals 
of  man  and  woman.  The  form  takes  on  a  manly  type,  the  beard  grows,  and 
the  voice  completes  the  change  that  has  begun  at  puberty.  In  the  woman,  the 
form  rounds  up  towards  the  ideal  type  of  beauty,  the  mammse  develop,  and  the 
whole  woman  is  perfected.  Now,  if  we  find  those  changes  taking  place  normally 
during  the  time  that  a  patient  is  subject  to  these  recurrent  attacks  of  mental 
excitement,  then  we  form  a  favourable  prognosis.  Nature  has  in  such  adolescents 
gone  through  the  strain  laid  on  her,  and  there  is  a  reasonable  probability  that 
the  tendency  to  mental  disturbance  has  passed,  at  aU  events  until  child-bearing 
or  the  climacteric  occurs. 

In  a  certain  proportion  of  the  cases  of  adolescent  mental  disturbance  (about 
22  per  cent),  it  takes  the  form  of  depression  that  is  also  apt  to  abate  and  recur, 
though  not  quite  in  the  same  degree  as  the  acutely  excited  cases.  The  prognosis 
in  the  melancholic  cases  is  better  than  those  of  mania.  Taking  the  whole  of  the 
mental  disturbances  of  adolescence  into  account,  they  recover  at  the  rate  of 
60  per  cent ;  but  limiting  oneself  to  the  depressed  cases,  the  rate  of  recovery  is 
about  10  per  cent  more. 

Instead  of  exaltation  or  depression,  we  meet  with  stuporose,  confusional, 
and  lethargic  symptoms,  sometimes,  too,  with  catalepsy  and  '  trance.'  The 
prognosis  is  not  so  good  in  such  patients,  but  is  by  no  means  very  bad. 

The  worst  class  of  symptoms  in  regard  to  prognosis  are  those  which  Kraepelin 
selects  as  constituting  his  dementia  praecox,  of  which  I  shaU  speak  presently. 
I  had  always  held  that  the  man  who  could  tell  us  in  the  early  stages  of  any 
case  of  adolescent  insanity  the  symptoms  which  indicated  incurability,  would 
add  greatly  to  our  exact  knowledge  of  psychiatry,  and  I  welcomed  Kraepelin's 
induction  accordingly. 

There  is  an  undoubted  liability  to  a  recurrence  of  mental  disturbance  in  those 
who  have  had  an  attack  at  adolescence  and  have  recovered.  Tracing  them 
through  their  whole  lives  I  find  that  nearly  20  per  cent  are  liable  to  a  recurrence 
in  some  form  or  other. 

The  gravest  aspect  of  adolescent  insanity  is  that,  in  about  one-third  of  the 
cases,  instead  of  recovering,  they  pass  slowly  into  dementia.  Nature  has  not 
been  able  to  bear  the  strain  of  the  period  of  complete  development,  and  the 
young  man  or  woman  virtually  dies  as  regards  all  the  highest  qualities  of  mind. 
I  believe  that,  in  most  of  those,  dementia  is  inevitable  from  the  beginning.  No 
methods  of  prophylaxis  or  treatment  would  have  had  much  effect  in  saving 
their  mental  life.  It  is  this  fact  that  makes  me  look  on  them  as  having  some 
analogy  to  the  cases  of  congenital  imbecility  in  which  a  mental  death  has  taken 
place  in  the  earliest  periods  of  life.  The  brain  of  the  imbecile  has  been  '  unfit  ' 
from  the  beginning,  the  brain  of  the  adolescent  was  fit  up  to  twenty,  and  then 
became  unfit  from  some  deeply-seated  hereditary  cause. 

In  addition  to  imbecility  and  adolescent  insanity,  we  notice  during  brain 
development  a  series  of  lesser  mental  and  moral  changes,  states  of  perverse 
conduct  and  peculiarities,  which  are  due  to  the  same  hereditary  defects,  and  are, 
in  many  ways,  of  the  same  essential  nature  as  technical  mental  disease.     Those 


MENTAL     DISEASES  335 

frequently  occur  at  earlier  ages  than  adolescent  insanity,  sometimes  even  before 
puberty.  They  consist,  in  some  cases,  of  stupidity  and  lethargy,  in  others  of 
perversions  of  the  social  instincts,  in  others  of  causeless  aversions  to  father, 
mother,  or  other  near  relations.  Some  show  their  peculiarities  in  an  abnormal 
intolerance  of  control,  incompatibihty  of  temper,  and,  in  some,  in  immoralities 
and  criminal  acts.  It  is  a  striking  fact  that  one-half  of  all  convictions  for  crime 
are  found  in  offenders  under  the  age  of  twenty-five.  There  are  many  cases  of 
the  morbid  impulsiveness,  the  losses  of  control,  and  the  tendencies  to  drink 
which  I  have  described  that  occur  at  that  age.  Most  of  such  cases  are  ascribed 
simply  to  bad  conduct,  which  the  parent  and  the  schoolmaster  usually  treat 
bj'  punishments.  A  few  of  such  cases  recover  from  those  mental  and  moral 
peculiarities  towards  the  end  of  adolescence,  but  unfortunately  the  outlook  is 
bad  in  most  of  them,  and  they  remain,  so  long  as  they  live,  the  bad  citizens, 
the  skeletons  in  families,  and  the  criminals  of  society. 

Dementia  Praecox. — Since  I  first  segregated  those  forms  of  insanity  just 
described  and  called  them  '  Adolescent  Insanity,'  Kraepelin,  of  Munich,  has 
segregated  a  group  of  mental  cases  occurring  about  the  same  age,  which  he  has 
called  '  Dementia  Praecox,'  and  holds  they  form  a  distinct  variety  of  mental 
disease,  with  distinctive  symptoms  and  history.  That  term  covers  the  un- 
favourable region  of  adolescent  insanity.  Those  who  recover,  Kraepelin  would 
include  in  his  'Manic-depressive  Insanity.'  The  chief  features  of  dementia 
praecox  are  that  it  begins  slowly  over  a  period  of  years,  and  the  patient  shows 
his  disorder  more  by  what  he  does  than  by  what  he  says  and  thinks.  He  shows 
odd  or  bizarre  conduct.  The  emotional  tone  is  blunted  and  changed.  There  is  a 
peculiar  loss  of  consistency  between  ideation,  emotion,  and  will.  The  will-power 
is  per\'erted  or  lost,  the  conduct  is  automatic,  there  are  what  is  called  negativism, 
'  stereotypism,'  apathy,  mannerisms,  and  indifference  to  personal  appearance. 
The  patient  often  has  hallucinations,  and  is  completely  changed  in  character. 
Ivraepelin  divides  the  cases  into  three  forms  :  (  i )  The  '  Katatonic,' 
(2)  'Hebephrenic,'  and  (3)  'Paranoid.'  All  three  varieties  are  unfavourable  as 
to  prognosis,  but  the  first  and  second  are  better  in  this  respect  than  the  third. 
Many  of  the  katatonic  are  those  which  I  have  described  under  '  Stupor,'  and 
we  have  seen  that  the  chances  of  recovery  are  on  the  w-hole  favourable  in  this 
form.  But  all  forms  tend  to  be  deteriorating  psychoses.  If  rightly  diagnosed, 
aU  cases  of  dementia  praecox  should  be  incurable. 

The  Mental  Disturbances  of  Decadence — The  Climacteric,  and  Senility. — 
When  we  come  to  that  period  at  which  men  and  women  turn  the  corner 
of  life,  when  they  pass  into  the  first  stage  of  decadence  and  involution, 
and  particularly  when  they  arrive  at  its  later  stages,  in  old  age,  some 
of  them  are  Uable  to  certain  forms  of  mental  disturbance,  the  symptoms  of 
which  are  markedly  different  from  those  in  the  earlier  periods  of  life.  The 
pathological  in  them  has  a  close  relationship  and  resemblance  to  the  physio- 
logical characteristics  of  those  eras  of  life.  The  passions  of  life  have  lost  their 
intensit}',  its  ideals  and  emotions  are  less  keen,  the  driving  power  of  sex  and 
all  that  it  imphes  in  life  is  fading  away  or  is  past,  the  general  result  being  that 
when  the  mind  becomes  unsound  it  tends  towards  melancholy,  to  a  want  of 
interest  in  life,  to  a  tedium  vitce,  and  a  general  diminution  in  originating  and 
energizing  power.  There  are  bodily  changes  pointing  to  the  same  general 
result.  The  red  corpuscles  of  the  blood  markedly  diminish  in  number,  certain 
glands  lessen  in  bulk,  the  countenance  and  eye  are  less  mobile  and  expressive  ; 
poetry,  fiction,  and  love  tales  cease  to  have  the  power  to  set  the  brain  on  fire. 
The  general  social  instincts  remain,  but  they  assume  different  forms  from  those 
of  youth.     The  subtle  interest  of  the  society  of  the  other  sex  is  less  overmastering. 


336  INDEX     OF     PROGNOSIS 

Friendship  and  comradeship  take  the  place  of  love  of  the  fervid  sort.  The 
climacteric  period  begins  in  the  woman  earlier  than  in  man,  and  its  signs  are 
more  marked ;  but  it  also  occurs  in  man  at  a  later  period  of  life,  and  in  a  less 
marked  form.  The  '  grand  climacteric  '  of  the  Romans  may  be  put  down  in  man 
as  occurring  at  about  the  age  of  sixty-three.  In  some  of  the  lowest  animals 
reproduction  is  at  once  followed  by  death  ;  in  man  the  loss  of  the  power  of  repro- 
duction is  followed  by  a  lessened  mental  and  bodily  intensity.  The  symptoms 
of  climacteric  unsoundness  of  mind  in  five  cases  out  of  six  takes  a  melancholic 
character.  The  sleep  becomes  broken,  the  appetite  for  food  is  less  intense,  the  skin 
gets  muddy,  the  patient  has  fears  and  fancies,  sometimes  of  an  intense  character. 
She  is  often  terrified  that  she  will  lose  control  over  herself  or  even  commit  suicide. 
She  blames  herself  for  all  those  feelings,  and  this  is  a  cause  of  distress.  Work  is 
difficult.  In  some  cases  there  are  hallucinations  of  hearing.  In  men,  initiation, 
courage,  and  mental  aggressiveness  are  lessened.  There  is  often  a  tincture 
of  hypochondria  in  the  mental  symptoms,  and  a  feeling  that  life  is  no  longer 
worth  having. 

The  prognosis  in  those  conditions  is  not  so  unfavourable  as  is  commonly 
supposed.  It  must  be  kept  in  mind  that  the  epoch  is  not  a  sudden  one.  It 
begins  slowly,  and  it  takes  several  years,  at  least  five  in  most  cases,  to  get  com- 
pleted. In  women  57  per  cent  recover,  but  in  men  only  31  per  cent.  I  do 
not  give  up  hope  of  recovery  in  a  climacteric  case  for  at  least  five  years.  The 
signs  of  recovery  are  a  return  to  a  reasonable  enjoyment  of  life,  but  with  less 
intensity  in  it.  Weight  should  be  gained,  fat  should  be  put  on,  the  sleep  should 
become  normal.  The  post-climacteric  happiness  and  power  of  work  are  not 
as  great  as  in  the  former  life,  but  there  are  many  women  of  the  nervous  tempera- 
ment who  experience  a  quiet  comfort  and  happiness  which  they  have  never 
enjoyed  before.  The  storms  of  life  are,  as  it  were,  past;  the  patients  have  sailed 
into  smooth  water.  During  the  climacteric,  whether  normal  or  abnormal  in 
its  character,  I  have  a  profound  belief  in  changes  of  environment,  and  especially 
in  living  in  the  fresh  air.  Suicidal  feelings  must  be  carefully  looked  for  in  both 
sexes,  because,  though  these  are  not  usually  intense,  yet  there  are  exceptions 
to  this  rule.  There  are  a  few  cases  of  climacteric  unsoundness  in  both  sexes 
that  assume  the  exalted  form  ;  agitated  melancholia  also  occurs.  My  experience 
is  that  the  more  acute  and  decided  the  mental  symptoms  are,  the  less  chance 
there  is  of  recovery.  When  those  acute  symptoms  abate,  the  patients  are  apt  to 
pass  into  a  senile  condition  before  the  usual  age  of  dotage. 

Old  Age. — The  normal  psychology  of  old  age  has  been  frequently  depicted , 
from  Shakespeare's  King  Lear  onwards,  but  an  exact  scientific  record  which 
takes  into  account,  not  only  the  heredity  of  mental  breakdown,  but  the  heredity 
in  regard  to  long  life,  has  not  been  made  as  yet ;  especially  the  brain  point  of 
view :  its  vascular  and  its  cellular  elements  have  not  been  taken  into  account  as 
they  should  have  been.  Many  cases  of  breakdown  in  old  age  are  primarily  due 
to  vascular  conditions  and  consequently  insufficient  blood-supply  to  the  nerve 
cells.  Atheroma  and  arteriosclerosis  are  both  very  common  in  all  degrees,  in 
old  people.  Sometimes  they  are  general,  sometimes  localized.  The  blood- 
pressure  is  always  increased  in  old  age  on  account  of  the  loss  of  elasticity  in  the 
arteries.  The  brain  at  that  time,  neither  in  its  vessels  nor  its  cells,  can  stand 
too  much  alcohol,  though  the  immediate  effect  of  that  substance  is  often  cheering 
and  comforting.  Heredity  comes  in  as  a  predisposing  cause  of  senile  changes  in 
an  apparently  less  degree  than  in  any  other  forms  of  mental  unsoundness  except 
general  paralysis  ;  but  the  facts  about  heredity  are  further  back  and  more  apt  to 
be  forgotten.  Senile  insanity  is  apt  to  assume  one  of  three  forms  :  either  a 
melancholia  like  the  climacteric  form,  or  a  maniacal  period  of  excitement,  or  a 


MENTAL    DISEASES  337 


condition  of  senile  dementia  which  may  be  the  termination  of  the  other  two 
forms.  My  experience,  from  the  study  of  hundreds  of  cases  of  senile  insanity,  is 
that  about  one-third  of  them  were  of  the  depressed  type,  and  of  these  30  per 
cent  recovered,  some  of  them  completely,  and  in  others,  all  the  acute  sym- 
ptoms passed  away,  so  that  they  could  return  to  their  homes.  This  form  of  the 
disease  does  not  necessarily  end  in  either  dementia  or  death.  One-tenth  of  the 
cases  had  acute  attacks  of  excitement,  in  fact,  in  many  cases,  acute  mania. 
Some  of  these  were  short  sharp  brain  storms  preceding  death,  or  outbursts 
of  delirious  excitement  accompanying  the  break-up  of  the  organism.  They 
are  exceedingly  apt  to  precede  attacks  of  paralysis,  and  most  of  them  are 
accompanied,  if  not  caused,  by  vascular  disease.  While  few  of  these  recover, 
yet  this  som.etimes  happens,  but  in  an  imperfect  degree. 

In  regard  to  cases  of  simple  senile  dementia  or  aggravated  dotage,  these  are 
not  commonly  sent  to  institutions,  and,  if  possible,  should  not  be  so  sent.  As 
might  be  expected,  the  cases  of  senile  mental  depression  that  occur  in  the  earlier 
semle  stages,  that  is,  from  seventy  to  seventy-five,  are  apt  to  show  less 
arterial  disease,  and  therefore  recovery  takes  place  in  a  real  and  complete  form. 
The  risk  of  speedy  death  in  most  of  them  is  considerable.  Thirty  per  cent  die 
as  the  result  of  their  attacks,  one-half  of  them  being  within  the  first  six  months 
of  a  residence  in  institutions.  The  acuter  class  of  cases  is  extremely  difficult  to 
manage  on  account  of  the  sleeplessness  and  restlessness.  It  needs  the  very 
best  nursing  arrangements  to  cope  with  them,  and  if  they  are  not  provided 
the  risk  of  death  is  very  great.  Exhaustion,  bedsores,  gangrene,  paralysis, 
are  all  common. 

I  have  commonly  found  that  the  mUder  degrees  of  senile  excitement  may  in 
the  beginning  be  effectually  treated  by  small  doses  of  the  bromide  of  potassium 
and  sulphonal,  beginning  with  not  more  than  five  grains  of  the  sulphonal  and 
ten  grains  of  the  bromide  twice  a  day  at  the  most,  and  as  an  occasional  night 
sedative. 

If  a  case  responds  to  this,  and  the  acute  restlessness  subsides,  with  a  reasonable 
amount  of  sleep  at  night,  the  patient  is  manifestly  much  the  better  for  it.  It 
gives  him  the  brain  rest  that  is  so  much  needed  in  these  cases,  and  it  should  not 
interfere  with  the  appetite.  After  a  week  or  two  the  medicines  should  frequently 
be  omitted  experimentally  to  see  if  the  patient  can  do  without  them.  Insomnia 
notoriously,  in  many  cases,  becomes  a  brain  habit,  and  by  breaking  the  habit 
and  re-forming  the  habit  of  sleeping,  the  patient  may  often  go  on  without 
sedatives  or  hypnotics.  It  is  always  desirable,  if  there  are  means  and  proper 
nursing,  and  arrangements  can  be  provided,  that  an  old  man  or  woman  should 
stay  at  home  and  not  be  sent  to  an  institution.  This  seems  somehow  to  be  the 
natural  right  of  any  citizen,  and  is  almost  always  greatly  appreciated  by  near 
relations.  There  are  some  senile  cases,  however,  even  at  the  advanced  ages, 
whose  symptoms  are  so  acute,  so  troublesome,  and  so  exhausting  to  all  who  have 
to  do  with  them,  that  institution  treatment  is  necessary ;  but  all  good  institutions 
now  have  hospital  wards  where  the  arrangements  are  specially  adapted  to  treat 
such  cases. 

Rarer  Etiological  and  Clinical  Forms  of  Mental  Disease. 

In  addition  to  these  etiological  and  clinical  forms  of  mental  disease,  of  a 
somewhat  definite  type,  there  are  many  others  of  a  less  common  kind  : — 

Mental  Symptoms  from  Influenza. — Since  the  year  1890,  when  the  first 
great  wave  of  influenza  swept  over  the  country,  there  have  been  a  large  number 
of  cases  where  the  primary  disease  was  complicated  by  nervous  and  mental 
symptoms.     In  fact,  it  may  be  said  that  every  attack  of  influenza  in  some  way 

22 


338  INDEX     OF     PROGNOSIS 

or  in  some  degree  lowers  the  nervous  tone,  either  during  the  attack  or  after- 
wards. These  results  often  assume  the  form  of  depression  of  spirits,  and  a 
lessening  of  the  nervous  energy,  which  lasts  for  weeks  and  sometimes  for  months 
after  the  actual  disease  has  passed  away.  Many  of  us  who  have  had  severe 
attacks  of  influenza  feel  that  we  have  been  the  worse  for  it  permanently.  I  have 
been  in  the  habit  of  saying  that  influenza  has  left  the  nervous  and  mental  tone 
of  Europe  and  America  lower  by  many  degrees  than  it  found  it.  Some  of  the 
cases  of  melancholia  were  very  marked  in  both  their  bodily  and  mental  symptoms. 
They  had  depression  of  mind,  lethargy,  a  feeling  that  life  was  scarcely  worth 
having,  anaemia,  want  of  appetite,  digestive  troubles,  or  loss  of  weight.  I  do 
not  say  that  there  is  any  post-influenzic  insanity  of  a  special  type.  I  have  seen 
the  motor  energy  of  the  body  affected  so  that  it  simulated  early  general  paralysis. 
I  have  seen  the  memory  markedly  affected  for  many  months.  I  have  seen 
cases  where  a  drink  craving  was  established  for  the  first  time.  The  treatment 
of  all  these  conditions  is  very  well  known — rest,  mostly  in  bed,  tonics,  change  of 
air,  careful  attention  to  diet,  and  freedom  from  business  anxiety.  Most  of  the 
influenzic  cases  recover  after  a  few  weeks  and  respond  to  treatment  readily. 
The  great  thing  is  to  keep  up  the  treatment  and  the  regime  for  a  considerable 
time  after  the  symptoms  seem  to  have  passed  away.  I  observed  a  curious  fact, 
which  may  be  a  coincidence,  that  after  the  great  epidemic  of  influenza  of  1890, 
which  affected  almost  everyone,  the  general  type  of  mental  disease  sent  to 
the  Royal  Edinburgh  Asylum,  which  admits  all  classes  of  society,  became  more 
of  a  melancholic  type  than  it  had  previously  been.  Before  that,  states  of  morbid 
elevation  prevailed  largely  over  those  of  depression.  Since  that  time  the 
melancholies  have  almost  equalled  in  number  the  maniacal  cases,  and  in  some 
years  have  exceeded  them. 

Diabetic  Mental  Symptoms. — A  very  large  number  of  the  cases  of  diabetes 
have  some  mental  or  nervous  symptom  in  addition  to  the  liability  to  diabetic 
coma.  It  usually  takes  the  form  of  depression,  irritability,  and  incapacity  to  do 
the  usual  amount  of  work,  mental  or  bodily.  I  have  seen  acute  cases  of 
melancholia  arising  in  diabetes,  who  mostly  died  of  the  attack.  The  treatment 
of  these  nervous  and  mental  affections  is  that  of  diabetes,  and  the  prognosis  is 
certainly  very  unfavourable. 

Blight's  Disease  with  Mental  Symptoms. — A  few  cases  of  Bright's  disease 
show  marked  mental  symptoms,  usually  of  the  toxic  character.  It  begins  with 
irritability  and  moroseness,  passing  into  acutely  maniacal  symptoms  with 
periods  of  delirium.  This  condition  I  look  on  as  an  equivalent  of  the  convulsions 
that  are  common  in  the  disease,  probably  determined  by  the  fact  that  the 
patients  had  a  bad  neurotic  heredity  which  rendered  them  more  than  normally 
liable  to  be  affected  by  any  toxin  in  their  higher  cortical  regions. 

Phthisical  Insanity. — The  early,  and  what  used  to  be  called  the  prodromal 
stage  of  phthisis  is,  in  a  certain  number  of  cases,  accompanied  by  somewhat 
distinctive  mental  symptoms :  suspicion,  slight  mental  enf eeblement,  unsociable- 
ness,  mild  attacks  of  excitement,  incapacity  to  follow  regular  employment,  with 
digestive  and  nutritional  weakness,  which  I  called  "  Phthisical  Insanity."  My 
study  of  this  condition  led  me  to  believe  that  about  3  per  cent  of  the  cases  sent 
to  mental  hospitals  were  of  tliis  character.  I  used  to  think  that  it  was  a  very 
incurable  form  of  mental  affection,  but  the  modern  treatment  of  phthisis,  when 
applied  to  those  cases,  results  in  a  larger  number  of  cures  than  I  used  to  see.  I 
now  believe  that  the  cause  of  such  mental  disturbances  is  due  to  the  toxic 
influence  of  the  tubercle  bacfllus  on  the  brain  in  persons  specially  predisposed 
to  mental  disease.  The  recovery-rate  of  this  psychosis  under  the  present  treat- 
ment of  phthisis  may  be  put  down  as  about  50  per  cent. 


MENTAL     DISEASES  339 

Mental  Symptoms  in  Acute  Rheumatism  and  Chorea. — In  a  few  cases  of  the 
typical  acute  rheumatism  which  we  used  to  see  before  the  saUcyUc  treatment 
was  introduced,  the  patients  would  suddenly  become  very  acutely  maniacal, 
this  being  accompanied  with  an  extremely  active  form  of  chorea.  The  rheumatic 
temperature  would  keep  up  during  this  state,  while  the  joint  affections  would 
cease.  Most  of  the  cases  recovered,  but  in  a  few  death  took  place  during  such 
acute  attacks.  I  have  no  doubt  whatever  that  these  resulted  from  a  metastasis 
of  the  rheumatic  toxin  or  micro-organism  from  the  joints  to  the  spinal  cord  and 
brain  cortex.  It  was  very  relapsing  in  character,  in  this  way  following  the 
lines  of  uncomplicated  rheumatism.  Its  treatment  is  that  of  the  acute  rheu- 
matism, by  salicylates,  etc.  Too  few  cases  have  been  put  on  record  to  give 
reliable  statistics  of  curability.  My  impression  is  that  such  cases  are  far  less 
frequently  seen  now  under  the  modern  treatment  of  acute  rheumatic  fever 
than  formerly. 

The  ordinary  chorea  of  early  adolescence  is  complicated  in  a  few  cases  by  a 
delirium  accompanying  the  inco-ordinated  muscular  movements.  The  patients 
first  show  depression  and  then  this  delirious  mania,  which  may  be  accompanied 
by  acts  of  violence  and  suicide.  Most  of  such  cases  recover,  but  there  are  a  few 
who  die  of  exhaustion.  The  treatment  is  that  of  chorea  plus  the  employment 
of  hypnotics  and  nerve  sedatives.  We  may  have  to  resort  to  hyoscine  in  some 
of  the  cases,  and  its  effects,  by  diminishing  the  motor  symptoms,  often  give 
extreme  relief,  for  the  time  being  at  least.  Most  of  the  cases  recover  soon  and 
have  no  relapses. 

Masturbational  Mental  Symptoms. — The  habit  of  masturbation  is  a  frequent 
accompaniment  of  many  forms  of  mental  disease,  and  in  that  case  it  always 
aggravates  the  mental  symptoms,  tending  to  produce  mental  irritability  and 
confusion.  On  the  whole  it  worsens  the  prognosis  if  persistent.  There  is  in 
addition  a  distinct  form  of  insanity  associated  with  and  caused  by  masturbation. 
This  is  not,  however,  nearly  so  common  as  is  popularly  and  even  medically 
supposed.  It  is  far  more  frequently  a  symptom  than  a  cause,  and  when  present 
it  is  not  nearly  so  incurable  a  malady  as  is  imagined.  My  experience  is  that 
35  per  cent  of  my  cases  of  the  disease  made  good  and  mostly  permanent 
recoveries  under  right  bodily,  mental,  and  moral  treatment.  Some  of  those 
cases  had  a  tinge  of  congenital  mental  weakness  which  was,  of  course,  incurable. 

Myxoedema  and  Exophthalmic  Goitre.— The  mental  symptoms  which  are 
liable  to  accompany  these  two  conditions  are  fairly  well  known.  In  both  cases 
they  often  become  so  severe  that  patients  have  to  be  sent  for  treatment  to  mental 
hospitals ;  at  least  that  was  so  in  the  case  of  myxoedema  before  its  treatment  by 
thyroid  extract  was  discovered.  The  symptoms  are  in  some  cases  depression, 
and  in  some,  exaltation  of  mind,  but  they  all  have  tendencies  to  hallucinations 
of  hearing.  They  all  have  a  lowered  vasomotor  tone,  a  slowness  in  the  reaction 
time,  and  a  general  lethargy  of  voluntary  movement.  All  the  cases  I  have  had 
since  the  thyroid  treatment  was  discovered  have  recovered. 

The  mental  symptoms  in  exophthalmic  goitre  are  irritability,  a  tendency  to 
delusions  of  suspicion,  and,  in  the  worst  cases,  acute  mania  of  an  extremely 
fatal  character.  Accompanying  such  mental  symptoms  are  the  usual  bodily 
signs  of  the  disease.  We  are  yet  waiting  the  entirely  satisfactory  treatment  for 
the  disease.  A  surgical  removal  of  part  of  the  thyroid  gland  has  lately 
been  reported  by  several  surgeons  to  have  good  results. 

The  Delirium  of  Young  Children. — The  delirium  to  which  all  children  are 
liable  from  high  temperatures  and  toxic  causes  is,  in  some  cases,  so  intense 
and  prolonged  as  to  become  a  cause  of  anxiety.  Such  delirious  conditions  mean 
that  the  children  affected  by  them  are  of  an  extremely  neurotic  temperament, 


34°  INDEX     OF     PROGNOSIS 

this  complicating  almost  every  form,  of  disease  to  which  they  are  liable.  It 
means  also  that  such  children  should  be  specially  cared  for  in  after  life  with  a 
view  to  antagonizing  the  effects  of  their  temperament.  The  fact  should  be 
taken  into  consideration  in  many  cases  in  education,  selecting  employments,  etc. 
The  Mental  Symptoms  of  Lead  and  Arsenical  Poisoning. — The  salts  of  these 
two  metals,  when  slowly  absorbed  into  the  system  by  painters  and  those  who 
have  drunk  much  beer  adulterated  with  arsenic,  are  liable  to  cause  mental 
symptoms  which  may  go  on  to  coma.  Hallucinations,  morbid  elevation,  maniacal 
attacks,  and  delusions  of  persecution  are  the  chief  symptoms.  There  have 
been  cases  of  coma  and  death  following  such  symptoms,  but  most  of  the  cases 
will  recover  if  proper  treatment  is  applied  in  time. 

The    General    Prognosis    in    Persons    with    a    Mental    and    Neurotic 
Heredity    but    no    actual  Mental    Symptoms. 

The  change  from  a  potentiality  and  tendency  into  an  actual  mental  disease 
is  always  an  uncertain  matter  on  account  of  the  absence  of  reliable  statistics 
and  of  scientific  prognostic  indications,  as  well  as  by  the  fact  that  the 
tendencies  to  actual  disease  through  hereditary  defects  vary  so  infinitely  in 
their  strength  in  different  cases. 

The  risks  of  the  occurrence  of  mental  disease  in  many  persons  are  a  question 
constantly  referred  to  doctors  nowadays,  but  it  is  rare  that  a  certain  prognosis 
can  be  given  in  any  individual  case.  So  much  depends  on  the  circumstances 
and  environment  of  the  person,  on  his  employment,  on  his  innate  vitaUty  and 
general  health,  and  on  his  habits  of  life,  as  well  as  on  his  heredity,  that  our  con- 
clusions are  made  uncertain  in  most  cases.  On  the  one  hand  a  certain  amount 
of  bad  heredity  exists  in  so  many  families  that  we  must  not  draw  too  fine  a 
line,  and  on  the  other  the  evil  consequences  to  the  individual,  to  the  family, 
and  the  race  may  be  so  great  that  we  must  not  shirk  from  pointing  out  the 
obvious  risks.  There  are  in  fact  prognostic  risks  that  may  be  taken  by  any 
man  or  woman  in  choosing  a  profession,  in  choosing  a  residence,  or  in  getting 
married,  but  on  the  other  hand  there  are  risks  that  no  prudent  and  conscien- 
tious man  or  woman  should  take.  The  chief  consideration  which  should  guide 
the  medical  adviser  are  the  strength  and  directness  of  the  evil  heredity  and  the 
constitution  of  the  person  about  whom  our  advice  is  sought.  In  every  case 
I  would  say  to  the  applicant  for  advice  that  our  present  knowledge  of  heredity 
is  defective  and  uncertain,  so  that  we  may  be  mistaken  in  our  conclusions. 

The  following,  I  would  say,  are  the  most  relevant  facts,  so  far  as  our  present 
knowledge  goes : — 

1.  Mental  disease  in  the  father  or  mother  implies  a  considerable  and  necessary 
risk  in  the  offspring. 

2.  The  risk  is  greater  from  the  father  to  the  daughter  or  from  the  mother  to 
the  son,  especially  if  there  are  also  bodily  or  mental  likenesses. 

3.  On  the  whole  there  is  more  risk  from  the  maternal  side. 

4.  If  mental  disease  has  been  common  '  in  the  family,'  the  risks  are  the 
greater. 

5.  If  the  person  about  whom  our  advice  is  asked  is  obviously  '  neurotic  '  in 
constitution,  and  has  '  stigmata  of  degeneration,'  bodily  or  mental,  the  risks 
are  thereby  accentuated. 

6.  If  the  general  health  has  been  much  below  par,  especially  during  the  period 
of  development,  the  risks  are  greater. 

7.  If  any  developmental  diseases  have  occurred,  such  as  convulsions,  asthma, 
chorea,  severe  hysteria,  tubercular  affections,  etc.,  even  though  they  may  have 
been  recovered  from,  the  risk  is  greater. 


MIGRAINE  341 


8.  If  mental  affections  have  appeared,  in  near  relations,  in  the  early  periods 
of'hfe,  the  risks  are  far  greater  than  if  they  have  appeared  later  on. 

9.  Many  of  the  neuroses,  notoriously  epilepsy,  occurring  in  ancestry,  are' 
liable  to  be  '  transformed  '  into  mental  attacks  in  descendants — mental  attacks 
are,  in  fact,  their  '  equivalents,'  looked  at  from  the  hereditary  point  of  view. 

10.  Alcohohc,  sjrphilitic  (including  general  paralysis),  traumatic,  and  toxsemic 
mental  attacks  may  not  necessarily  imply  any  mental  hereditary  element. 

11.  In  some  cases  mental  attacks  will  appear  in  members  of  a  family  with  an 
entirely  clean  bill  of  health  so  far  as  the  facts  are  ascertainable. 

T.  S.  Clouston. 

MEDITERRANEAN    FEVER.— (5ee  Tropical  Fevers.) 

MERCURIALISM. — Patients  who  are  affected  with  tremor  as  the  result  of 
inhaling  mercury  vapour  may  not  suffer  from  any  other  manifestation. - 
Removal  from  the  influence  of  the  poison  may  be  followed  by  rapid  recovery, 
though  in  some  cases  the  tremor  never  entirely  passes  away,  and  may  remain 
with  undiminished  intensity.  Nervous  symptoms  rarely  follow  the  medicinal 
use  of  mercurial  salts,  but  arise  most  frequently  in  those  who  work  with  the 
metal.  Weakly  people  suffer  much  more  severely  than  the  robust,  and  there 
is  a  very  marked  individual  susceptibility.  The  symptoms  may  arise  for  the 
first  time  when  an  interval  has  elapsed  since  the  last  exposure. 

With  regard  to  oral  administration,  it  is  stated  that  the  taking  of  3  gr.  of 
perchloride  of  mercury  has  been  followed  by  death.  On  the  other  hand,  a 
case  has  been  recorded  in  which  extensive  alveolar  necrosis  and  parenchymatous 
nephritis  followed  the  ingestion  of  7^^  gr.  of  perchloride  of  mercury,  and  in 
spite  of  this  the  patient  eventually  recovered. 

Of  the  more  acute  manifestations,  the  following  justify  a  very  grave  prognosis  : 
oedema  of  the  glottis  may  rapidly  follow  a  large  concentrated  dose,  leading  to 
speedy  death  from  asphyxia  ;  severe  gastro-intestinal  disturbance  with  frequent 
Tomiting  of  blood-tinged  material,  diarrhoea  with  bloody  evacuations  ;  exten- 
sive stomatitis  followed  by  sloughing  of  the  gums  and  the  inside  of  the  cheeks, 
and  sudden  collapse,  and,  in  somewhat  less  acute  cases,  marked  cachexia  with 
oedema  round  the  ankles.  The  prognosis  is  much  worse  if  there  is  any  coincident 
nephritis. 

Some  patients  die  with  acute  cerebral  symptoms,  beginning  perhaps  with 
hallucinations,  passing  on  to  a  stage  with  epileptiform  convulsions,  or  acute 
mania. 

Chronic  mercurialism  in  women  favours  miscarriage  and  the  birth  of  still- 
born children.  In  both  sexes  it  undermines  the  resistance  of  the  body  and  paves 
the  way  for  phthisis,  or  some  acute  infection.  /.  R.  Charles. 

MIGRAINE.  —  Migraine,  with  its  characteristic  paroxysmal  headaches, 
generally  unilateral,  frequently  preceded  by  the  well-known  visual  phenomena, 
and  usually  culminating  in  vomiting,  does  not  involve  any  direct  danger  to  life. 
Migraine  is  a  family  disease,  which  generally  appears  in  childhood,  and  sub- 
sequently recurs,  often  with  remarkable  periodicity,  at  intervals  of  about  three 
or  four  weeks  throughout  adult  life,  ultimately  tending  to  disappear  in  old  age. 
In  women,  the  attacks  are  specially  hable  to  occur  towards  the  end  of  each 
menstrual  period.  In  addition  to  the  natural  tendency  to  spontaneous  recur- 
rence, there  are  frequently  sources  of  peripheral  irritation  which  precipitate  or 
aggravate  an  attack  at  the  end  of  a  particular  cycle  of  time  in  each  patient's  case. 
Sometimes  the  recognition  and  correction  of  such  accessory  factors  as  errors  of 
refraction  (these  should  always  be  looked  for),  nasal  or  dental  abnormalities. 


342  INDEX     OF     PROGNOSIS 

gouty  diathesis,  etc.,  may  produce  a  remarkable  diminution  both  in  the  frequency 

and  in  the  severity  of  the  attacks ;  but  the  disease  is  essentially  a  hereditarj^  and 
constitutional  one,  and  therefore  entire  cessation  of  the  attacks  is  not  to  be 
expected.  Gowers  thinks  that  cases  in  which  the  face  becomes  cold  and  pinched 
during  the  attack  have  a  more  favourable  prognosis,  as  regards  mitigation  of 
the  attacks,  than  when  the  face  is  flushed  at  the  onset  of  the  paroxysms  ;  but  it  is 
difficult  to  be  sure  of  this.  Purves  Stewart. 

MITRAL  DISEASE. — {See  Heart,  Valvular  Disease  of.) 

MOLES  (Simple). — These  tumours  are  congenital  local  defects  of  development 
in  the  skin.  They  are  characterized  b}-  warty  overgrowth  of  the  papiUae,  and 
often  by  the  presence  of  hair,  but  above  aU  by  the  presence  in  them  of  groups 
of  chromatophores  or  pigmented  connective-tissue  cells,  which  give  to  the  mole 
its  characteristic  dark  colour.     In  certain  moles  pigment  is  absent. 

The  prognosis  is  good.  There  are  few  indi\-iduals  who  do  not  possess  them. 
But  in  two  contingencies  their  potential  mahgnancy  may  awake.  If  the  mole 
is  subjected  to  any  injury,  and  especially  to  chronic  irritation  such  as  chafing, 
melanotic  sarcoma  may  supervene,  heralded  by  increase  in  size  and  elevation, 
and  by  repeated  bleeding,  followed  by  enlargement  of  glands.  The  second 
contingency  is  injudicious  treatment.  Caustics  and  partial  excision  are  most 
dangerous.  Either  a  mole  must  be  severely  let  alone,  or  it  must  be  treated, 
like  the  aspiring  relatives  of  an  Oriental  despot,  by  complete  extirpation.  Clean 
excision  with  the  knife  should  alwaj^s  be  performed  when  the  mole  displays  signs 
of  activity,  and  in  any  case  if  it  is  subject  to  chronic  irritation,  as  on  the  sole  of 
the  foot,  the  inner  side  of  the  thigh,  the  neighbourhood  of  the  anus,  or  in  the 
region  of  the  coUar.  w.  Sampson  Hundley. 

MOLES,  VESICULAR. — The  dangers  of  a  vesicular  mole  are  :    (i)    Excessive 

hcBmorrhage  due  to  partial  separation  of  the  mole  ;  (2)  Perforation  or  rupture  of 
the  uterus  by  the  mole  ;  (3)  The  coincident  or  subsequent  development  of  chorio- 
carcinoma. 

1.  Excessive  Haemorrhage. — Great  bleeding  may  be  caused  by  a  vesicular 
mole,  but  it  is  rare  for  a  patient  to  die  from  this  cause  alone.  Even  after 
apparently  complete  spontaneous  extrusion,  it  is  usual  for  bleeding  to  go  on 
and  necessitate  uterine  exploration. 

All  vesicular  moles  should  of  course  be  removed  surgically.  More  than  this: 
even  after  apparently  complete  natural  expulsion,  it  is  safest  to  explore  the 
uterus,  so  as  to  be  sure  that  no  fragments  remain  capable  of  giving  rise  to 
chorio-carcinoma  subsequently. 

The  removal  of  a  vesicular  mole  is  accompanied  by  a  great  deal  of  bleeding, 
but  not  as  a  rule  sufficient  to  give  rise  to  anxiet\^  because  the  hsemorrhage 
provokes  surgical  interference  before  the  patient's  condition  has  become 
alarming. 

External  haemorrhage  is  most  marked  in  the  non-mahgnant  variety  of  these 
moles,  and  indicates  an  attempt  on  the  part  of  the  uterus  to  expel  the  mass. 
In  some  cases  this  is  successfully  accompUshed  ;  but  more  commonly  only  a 
portion  of  the  gro%vth  is  extruded,  because  the  adhesion  of  the  viUi  to  the  uterine 
wall  is  generally  far  firmer  than  obtains  in  normal  pregnancy. 

2.  Perforation  or  Rupture  of  the  Uterus. — Instances  have  been  recorded 
many  times,  but  the  event  is  relativelj-  rare.  In  a  certain  proportion  of  cases 
the  chorionic  vilh  penetrate  deeply  into  the  wall,  even  to  the  peritoneal  surface, 
and  in  such  cases  the  risk  of  perforation  during  exploration  or  curettage  is 


MOVABLE    KIDNEY  343 


evident ;  while  it  is  in  such  cases  that  spontaneous  rupture  occurs — during 
the  contractions  of  the  uterus  in  the  attempt  to  expel  the  mole.  The  internal 
hasmorrhage  in  such  cases  has  often  proved  fatal. 

3.  The  Coincident  Development  of  Chorion-epithelioma. — This  is  an  eventuahty 
for  which  one  must  always  be  on  the  look-out.  Findley,^  in  an  analysis  of 
210  cases  of  hydatid  mole,  found  that  16  per  cent  became  malignant.  It  has 
occurred  much  more  commonly  after  a  vesicular  mole  than  after  normal  preg- 
nancy or  ordinary  abortion.  The  earlier  writers  found  that  vesicular  mole  pre- 
ceded chorion-epithelioma  in  50  per  cent  of  the  cases  ;  but  in  later  researches 
the  percentage  is  somewhat  lower. 

These  growths  are  known  as  malignant  moles,  and  the  prognosis  is 
correspondingly  grave.  It  follows  that  every  case  of  vesicular  mole  must  be 
watched  for  at  least  a  month  or  two  after  treatment,  in  order  to  adopt  energetic 
measures  in  the  presence  of  untoward  symptoms.  Unfortunately,  it  happens 
that  no  great  reliance  can  be  placed  upon  the  histological  features  of  the 
chorionic  villi  in  vesicular  degeneration  as  giving  indications  of  malignancy. 

Complications. — Finally,  a  few  of  the  rarer  complications  of  vesicular  degenera- 
tion are  vomiting,  albuminuria,  and  even  eclampsia  and  sepsis.  In  these  cases 
a  condition  of  lowered  resistance  ensues  in  which  a  haemorrhage  may  be  attended 
by  a  rapidly  fatal  result,  or  in  which  a  septic  infection  is  prone  to  develop. 

Figures  relating  to  the  effect  of  molar  pregnancies  upon  fertility  are  lacking, 
but  there  exist  numerous  observations  in  which  pregnancy  has  supervened 
not  once,  but  on  several  occasions.  It  is  even  asserted  that  sterility  is  rare 
after  a  molar  pregnancy. 

Once  a  hydatid  mole  has  been  successfully  cleared  out,  there  are  no  remote 
effects  to  be  feared  beyond  the  possibility  of  subsequent  chorion-epithelioma 
developing. 

Mortality. — From  all  causes  Brindeau^  states  that  the  mortaUty  in  vesicular 
mole  is  about  15  per  cent  of  the  cases. 

In  the  figures  of  Findley,^  representing  210  cases  collected  from  the  Litera- 
ture, there  were  49  deaths,  a  mortality  of  about  25  per  cent.  Of  this  number, 
32  died  from  malignant  degeneration,  or  16  per  cent;  7  died  from  haemor- 
rhage, or  4  per  cent ;  4  from  septic  peritonitis,  or  2  per  cent ;  i  from  general 
sepsis,  I  from  uraemia,  i  from  endocarditis,  i  from  meningitis,  and  2  from 
unknown  causes. 

References. — ^Diseases  of  Women,  1914,  174  ;  "La  Pratique  de  VArt  de  V Accouche- 
ment, 1914.  Bryden  Glendining. 

MORPHIA  HABIT.—' (See  Drug  Habits.) 
MOUTH,  CANCER  OF.— (See  Tongue,  Cancer  of). 

MOVABLE  KIDNEY. — We  have  to  consider  the  outlook  from  the  patient's 
point  of  view,  first,  apart  from  operation,  and  secondly,  when  operated  on  by 
some  of  the  niany  methods  now  in  use. 

It  is  well  known  that  the  doctor  often  finds  a  movable  kidney  in  the  course 
of  a  routine  examination,  when  there  have  been  no  special  symptoms  connected 
with  it,  and  it  frequently  happens  that  nothing  is  ever  heard  about  it.  On 
the  other  hand,  severe  pain  or  a  wearying  sense  of  drag  may  make  the  patient's 
life  a  misery. 

A  number  of  secondary  consequences  may  appear. 

I.  Dietl's  Crises. — These  are  violent  attacks  of  pain,  with  haematuria,  due  to 
kinking  of  the  pedicle. 


344  INDEX     OF     PROGNOSIS 

2.  Intermittent  Hydronephrosis. — A  swelling  raay  be  felt  in  the  loin,  which 
periodically  disappears,  and  a  large  quantity  of  watery  urine  is  passed.  This 
may  be  due  to  other  causes  than  kinking  of  the  ureter  by  a  movable  kidney. 

3.  Secondary  Gastric  Symptoms. — It  has  recently  been  recognized  that  all 
the  symptoms  of  gastric  ulcer  (pain,  vomiting,  hsematemesis,  hyperchlorhydria, 
etc.)  may  be  induced  as  a  reflex  from  movable  kidney  as  weU  as  from  other 
abdominal  conditions,  such  as  appendicitis  and  gall-stones.  Indeed,  the 
hyperchlorhydria  may  actually  lead  to  the  development  of  a  gastric  ulcer. 
Of  38  cases  of  movable  kidney  operated  on  at  the  Bristol  Royal  Infirmary,  5 
developed  sooner  or  later  a  gastric  ulcer,  one  of  which  perforated  fatally.  In 
another  case  a  patient  was  explored  for  gastric  symptoms  and  nothing  was 
found,  so  the  kidney  was  fixed,  great  improvement  resulting. 

4.  Mental  Disturbance. — According  to  Suckling,  40  per  cent  of  all  women 
attending  a  neurological  clinic  have  a  movable  kidney,  and  their  nervous 
symptoms  are  reUeved  by  its  fixation,  so  that  he  takes  it  to  be  causative.  The 
great  majority  of  English  surgeons,  however,  do  not  think  it  justifiable  to 
operate  unless  there  is  definite  evidence  of  local  symptoms  referable  to  the 
kidney. 

The  prospects  of  cure  by  various  forms  of  pads,  belts,  and  corsets  are  difficult 
to  estimate.  Treves  states  that  nineteen  cases  out  of  twenty  obtain  some 
relief  from  Ernst's  apparatus,  and  that  it  may  be  left  off  after  two  years,  but 
other  experience  is  much  less  favourable,  and  the  patients  frequently  declare 
that  the  pain  is  no  better,  or  that  the  pressure  is  intolerable. 

Results  of  Operation  for  Movable  Kidney. — The  death-rate  is  not  very 
serious.  Edebohls  collected  records  of  846  cases  from  the  literature,  with  a 
mortality  of  1-65  per  cent.  Billington  has  operated  on  515  patients,  of  whom 
4  died.  At  two  Bristol  hospitals  there  was  i  death  (from  sloughing  of  the  wound) 
in  104  cases.     Probably  the  mortality  is  between  i  and  2  per  cent. 

ReUable  end-results  are  not  easy  to  obtain,  most  authors  giving  very 
inadequate  details,  or  only  following  the  cases  for  a  few  months.  Keen  mentions 
116  patients  whose  condition  was  investigated  afterwards,  but  in  some  cases 
this  was  only  three  months  after  the  operation.  He  found  58  per  cent  cured, 
13  per  cent  better,  and  20  per  cent  without  rehef  ;   but  details  are  lacking. 

Wilson  and  Howell  examined  41  cases  who  had  had  various  operations  at 
St.  Bartholomew's  Hospital  at  least  a  year  previously.  Twelve  were  quite 
cured  and  8  greatly  improved  ;  9  were  no  better.  The  acute  cases  did  better 
than  the  chronic.  In  several  patients  the  kidney  had  broken  loose  again,  but 
nevertheless  there  was  considerable  relief. 

BilUngton  has  followed  up  two  series  of  his  end-results.  In  the  first,  87  cases 
were  communicated  with  at  least  a  year  after  the  operation  ;  60  per  cent  were 
almost  or  quite  cured,  20  per  cent  much  better,  10  per  cent  better,  and  10  per 
cent  no  better.  In  a  second  series,  7  out  of  92  patients  were  reported  by  their 
doctors  to  be  no  better  ;  the  rest  were  cured  or  improved.  Billington,  how- 
ever, operates  on  a  type  of  patient  that  most  surgeons  would  not  consider  to  be 
sufficiently  disabled  by  the  symptoms  of  movable  kidney  per  se  to  warrant 
surgical  intervention,  for  instance,  neurasthenics  and  even  lunatics.  His  results 
are  therefore  not  comparable  with  those  of  others.  His  method  of  operating 
is  to  make  a  sUng  out  of  the  capsule  of  the  kidney,  combined  with  Goelet's 
sutures. 

Rovsing,  of  Copenhagen,  reports  on  a  series  of  cases  operated  on  from  one  to 
twelve  years  previously.  Out  of  these,  107  were  cases  of  uncomphcated  movable 
kidney,  whereof  85  per  cent  were  quite  cured,  9  per  cent  better,  4  per  cent  no 
better,   and  2  died   of  the  operation.      In  64   cases   complicated  by  pyelitis, 


MOVABLE     KIDNEY 


345 


appendicitis,  or  gastric  ulcer,  50  per  cent  were  cured,  25  per  cent  better,  22  per 
cent  no  better,  and  3  per  cent  died  of  the  operation.  The  method  was  to  make 
a  sling  out  of  the  capsule.  It  is  probable  that  patients  with  mild  symptoms, 
as  most  surgeons  would  judge  them,  were  submitted  to  operation. 

Mills  has  collected  the  results  of  nephropexy  at  the  General  Hospital,  Bir- 
mingham. He  investigated  57  cases  up  to  four  years  afterwards,  and  found  that 
33  per  cent  were  cured,  10  per  cent  better,  57  per  cent  no  better.  In  23  per  cent 
the  kidney  was  again  movable.  The  method  of  fixation  varied.  He  points  out 
that  the  patients  cured  were  all  characterized  before  operation  by  a  very 
significant  feature,  that  the  symptoms  were  relieved  when  they  lay  down. 
Thomson  Walker  lays  stress  on  the  same  observation. 

At  the  discussion  by  the  Royal  Society  of  Medicine  in  1914,  the  registrars  of 
three  London  hospitals  presented  reports  on  83  patients  two  or  more  years  after 
operation.  Of  these,  52  per  cent  were  cured  or  greatly  improved,  12  per  cent 
better,  and  36  per  cent  no  better. 

End-results  of  Operation  for  Movable  Kidney. 


Reporter 

Cases  lollowed 

Cured  or  nearly 
cured 

Better 

No  better 

per  cent 

per   cent 

per  cent 

Wilson  and  Howell     - 

41 

49 

29 

22 

Billington  .         -         -         . 
Rovsing — 

87 

60 

30 

10 

(a)  Uncomplicated  - 

(b)  Complicated 

Mills            .... 

107 
64 
57 

85 
50 
33 

9 
25 
10 

4 

22 

57 

3  London  hospitals     - 
2  Bristol  hospitals 

83 
69 

52 
58 

12 

18 

36 
24 

The  writer  has  investigated  the  end-results  of  69  operations  at  two  Bristol 
hospitals  under  the  care  of  various  surgeons.  Of  these,  40  were  cured  as 
far  as  the  kidney  trouble  was  concerned,  but  some  still  had  indigestion, 
or  pain  in  the  other  kidney;  16  were  not  improved.  Several  of  these  were 
undoubtedly  incorrectly  diagnosed  ;  one  proved  afterwards  to  have  a  dilated 
stomach.  Another  suffered  from  intermittent  hydronephrosis.  In  6  cases 
the  kidney  appears  to  have  broken  loose  again,  but  nevertheless  3  of  these 
are  much  improved.  Relapses  of  pain  took  place  respectively  five  weeks, 
six  weeks,  four  months,  nine  months,  a  year,  and  two  years  after  operation. 
In  the  last  case  the  kidney  slipped  during  a  sudden  strain,  but  the  symptoms 
have  almost  entirely  passed  off  again.  Cases  associated  with  hydronephrosis 
did  not  do  well. 

Although  the  number  of  cases  is  small,  some  evidence  is  forthcoming  as  to 
the  best  method  of  operating.     Four  procedures  are  represented  : — 

1.  Transcortical  Suturing,  catgut  or  silk  sutures  being  passed  through  the 
kidney  substance  and  the  muscles,  or  over  the  last  rib.  The  failures  are  5  out 
of  14,  which  is  a  large  proportion  ;    2  kidneys  became  loose  again. 

In  18  cases  the  kidney  was  sutured  to  the  muscles  with  catgut,  but  it  is  not 
clear  whether  the  cortex  or  the  capsule  was  pierced.  Of  these  11  were  cured, 
4  reheved,  and  3  no  better. 

2.  Suture  of  Capsule. — In  8  cases  the  capsule  was  sutured  to  the  muscles 
with  catgut.     Here  again  the  results  were  poor,  and  2  worked  loose. 

3.  Phenol  and  Sling. — The  kidney  was  painted  with  pure  carbolic  acid,  and 
an  iodoform  gauze  sling  put  in  beneath  the  lower  pole  and  left  ten  to  fourteen 


346 


INDEX     OF    PROGNOSIS 


days.  The  end-results  are  quite  good,  only  3  out  of  19  failing.  One  case  (not 
examined)  is  said  to  have  relapsed.  The  writer  has  seen  laceration  of  the 
kidney,  with  hsemorrhage  and  escape  of  urine,  follow  removal  of  the  gauze. 

4.  Goelet's  Method. — The  capsule  is  secured  by  two  mattress  sutures  of  silk- 
worm gut  passing  through  the  muscles  and  skin  at  a  higher  level.  Only  ten 
cases  appear,  but  the  results  are  not  so  good  as  the  last-named. 

End-results    after  Various    Operations. 


Method 

Cases 

Cured 

EeUeved 

No  better 

Suture  to  muscles 
Transcortical  suture  - 
Suture  of  capsule 

Phenol  and  sling 

Goelet's       .         .         -         . 

40 

u 

s 

19 
10 

22 
8 

3 
12 
6 

7 
1 

v> 

4  " 
2 

11 

5 
S 

3 

2 

We  may  conclude,  therefore,  that  by  nephropexy  probably  50  per  cent  will  be 
cured,  but  one  in  three  or  four  will  not  be  relieved  at  all.  Better  selection  of 
cases  will  doubtless  improve  on  these  results  in  the  future,  and,  in  particular, 
operation  is  not  advisable  unless  the  pain  is  relieved  by  recumbency.  The 
third  and  fourth  methods  just  mentioned  give  a  higher  proportion  of  cures, 
namely,  about  60  per  cent,  and  only  15  per  cent  of  failures. 

References.  —  Billington,  Movable  Kidney,  Cassell,  1910  ;  Wilson  and  Howell, 
Movable  Kidney,  London,  1908  ;  Rovsing,  Archiv.  /.  Min  Chir.  1914,  p.  183  ;  Mills 
and  others,  Proc.  Roy.  Soc.  Med.  Surg.  Section,    1914,  Feb.  p.  137. 

A.  Rendle  Short. 

MUMPS. — Mumps  is  only  exceptionally  fatal.  Amongst  58,331  cases  occur- 
ring in  Denmark  during  the  years  1870  to  1894  and  reported  by  Ringberg,  there 
were  only  7  deaths,  of  which  3  were  in  children.  Comby  states  that  there  was 
I  fataht}'-  amongst  496  cases  in  the  French  army  during  the  years  1862  to  1865; 
but  Denime,  at  Berne,  reported  2  deaths  in  117  cases.  It  is  rarely  fatal  except 
from  complications. 

Complications. — Orchitis  is  the  most  serious  comphcation  :  not  because  it  is 
at  all  frequently  associated  with  a  fatal  result,  for  that  is  not  the  case,  but  because 
it  often  terminates  in  atrophy  of  the  testis.  Orchitis  usually  sets  in  about  the 
seventh  or  eighth  day  of  the  illness,  but  may  occur  at  any  time  within  six  weeks  ; 
it  may  follow  a  mild  attack  of  mumps.  It  is  most  frequently  met  with  in  young 
men,  and  is  rare  in  little  boys  and  old  men.  Its  frequency  appears  to  vary 
considerably  in  different  epidemics.  Catrin  states  that  it  occurs  in  16  per  cent 
of  males  of  all  ages  ;  but  Laveran  and  Comby  put  the  incidence  much  higher, 
from  30  to  33  per  cent.  Comby,  however,  refers  only  to  epidemics  in  the  French 
army.     Catrin's  estimate  is  probably  nearest  the  truth. 

A  large  proportion  of  the  cases  of  orchitis  end  in  atrophy  ;  60  per  cent 
according  to  Catrin,  70  per  cent  according  to  Laveran. 

Very  severe  cerebral  symptoms  occasionally  arise  during  an  attack  of  mumps, 
either  during  the  parotitis  or  after  the  testis  has  become  affected.  But  as  a  rule 
such  symptoms  do  not  last  long,  and  the  patient  recovers  without  any  cerebral 
or  mental  after-effects. 

Pancreatitis  is  another  complication  which  is  accompanied  by  alarming 
symptoms.  It  usually  arises  within  a  week  of  the  onset  of  the  attack  of 
mumps.  It  has  been  known  to  occur  in  as  many  as  5  out  of  33  cases  (in  an 
outbreak   reported   by   Edgecombe).     There   may   be   severe   abdominal  pain. 


MUSCULAR    ATROPHIES  347 

vomiting,  and  collapse.     But  in  spite  of  the  apparent  severity,  the  prognosis 
is  nearly  always  favourable. 

Permanent  deafness  is,  in  rare  cases,  the  result  of  an  attack  of  mumps.  The 
cause  is  usually  inflammation  of  the  internal  ear.  e.  W.  Goodall. 

MUSCULAR    ATROPHIES. 

Arthritic  Muscular  Atrophy. — In  this  form,  which  accompanies  any  acute 
or  chronic  joint  affection,  and  which  is  limited  to  the  muscles  around  the  affected 
joint  or  joints — being  usually  more  marked  in  the  extensors  than  in  the  flexors, — 
the  prognosis  depends  upon  the  recovery  of  normal  mobility  in  the  affected  joint. 
The  absence  of  fibrillary  movements,  and  the  presence  of  electrical  reactions 
which  are  normal  or,  at  the  most,  merely  quantitatively  diminished,  are  here  of 
corroborative  value.  Suitable  massage  and  movements  of  the  affected  muscles 
and  joints  rapidly  produce  improvement,  the  ultimate  result  being  proportional 
to  the  degree  of  mobility  attained  at  the  particular  joint. 

Ischaemic  Muscular  Atrophy  (v.  Volkmann's  paralysis),  the  result  of  muscular 
compression  by  splints  or  bandages  which  have  been  too  tightly  apphed,  is  met 
with  only  in  the  forearm,  and  is  confined  to  the  muscles  on  the  flexor  aspect  of 
the  hand.  Within  a  few  hours,  the  forearm  muscles  become  tender,  and  the 
fingers  and  hand  swollen  ;  and  unless  the  splints  are  removed  and  properly 
adjusted  forthwith,  the  affected  muscles  are  gradually  infiltrated  by  fibrous 
tissue,  causing  them  to  become  hard  and  leathery  in  consistence,  with  impossi- 
bility both  of  active  contraction  and  of  passive  stretching.  In  this  variety  of 
muscular  atrophy,  due  to  interstitial  myositis,  the  contracture  of  the  wrist  and 
fingers,  once  established,  is  obstinately  resistant  to  the  most  energetic  massage 
and  electrical  treatment  ;  and  the  best  prospect  of  regaining  a  useful  limb  is 
offered  by  the  excision  of  a  portion  of  the  radius  and  ulna,  thereby  shortening 
the  forearm  to  correspond  with  the  shortened  flexor  muscles. 

Neuritic  Muscular  Atrophy  follows  lesions  of  motor  or  mixed  nerves,  whether  in 
isolated  affections  of  individual  nerve-trunks  (such  as  the  facial,  ulnar,  or  musculo- 
spiral),  or  in  multiple  neuritis  from  any  cause  (alcohol,  lead,  arsenic,  diabetes, 
beri-beri,  malaria,  diphtheria  and  other  infective  diseases,  etc.).  The  prognosis 
varies  according  to  the  underlying  cause,  and  according  to  the  degree  of  degenera- 
tion which  has  occurred  in  the  affected  motor  nerve.  Sometimes  the  cause 
cannot  be  removed,  as  in  diabetic  neuritis.  In  other  cases,  as  in  alcoholic 
neuritis,  it  is  removable  with  considerable  difficulty.  In  others  again,  as  in 
diphtheritic  and  malarial  neuritis,  and  in  ordinary  '  rheumatic  '  facial  palsy, 
there  is  a  tendency  to  spontaneous  recovery.  Accurate  diagnosis  of  the  cause 
is  therefore  of  supreme  importance.  The  degree  of  degeneration  that  has  occurred 
in  the  nerve  and  muscle  fibres,  in  any  particular  case,  is  determined  by  the 
examination  of  their  electrical  reactions. 

Myopathic  Muscular  Atrophy. — In  this  form — whether  of  the  pseudo-hyper- 
trophic  type,  or  of  the  primary  atrophic  type  (where  the  disease,  congenital  in 
origin,  consists  in  a  primary  decay  of  the  muscle-fibres,  with  a  reversion,  first,  to 
an  embryonic  structure,  and  ultimately  ending  in  disappearance  of  the  contractile 
sarcoplasm), — the  prognosis  is  unfavourable  as  regards  recovery.  The  rate  of 
progress  of  the  disease,  however,  varies  within  wide  limits.  Some  patients 
become  bedridden  and  helpless  within  a  few  years,  and  die  (from  some  inter- 
current disease)  before  attaining  adult  age.  In  others,  the  disease  advances 
with  extraordinary  slowness,  and  the  patient  may  be  able  to  get  about  for  thirty 
or  forty  years  after  the  onset  of  his  symptoms.  Other  cases,  again,  seem  to 
come  to  a  standstill,  and  remain  at  the  same  stage  of  muscular  atrophy  for  an 
apparently  indefinite  period.     Patients  with  myopathy,  however,  rarely  live  to 


348  INDEX     OF    PROGNOSIS 

an  advanced  age.  The  pseudo-hypertrophic  form  has  a  relatively  worse  prognosis 
as  regards  life  than  the  primary  atrophic  type. 

Progressive  Muscular  Atrophy  (peroneal  or  Charcot-Marie-Tooth  type),  which 
usually  begins  in  childhood  and  adolescence,  and  is  characterized  by  wasting  of 
the  peripheral  muscles  of  the  Umbs  which  leads  to  early  claw-hand  and  to  tahpes, 
bilaterally  symmetrical,  has  a  prognosis  very  similar  to  that  of  the  myopathies : 
i.e.,  it  progresses  with  extreme  slowness,  and  may  even  come  to  a  standstill. 
Here  the  prognosis  as  to  Ufe  depends  upon  preventing  the  patient  from  becoming 
bedridden.  The  orthopedic  surgeon  can  often  prolong  hfe,  either  by  providing 
suitable  supports  for  the  feet  and  knees,  or  by  various  operations  upon  the 
contractured  feet,  enabUng  the  patient  to  get  about,  even  when  all  the  muscles 
below  the  knees  are  completely  paralyzed. 

Progressive  Muscular  Atrophy  (chronic  anterior  poliomyelitis),  from  degenera- 
tion of  the  anterior  cornual  cells,  may  affect  the  spinal  cord  alone,  or  it  may  also 
attack  the  medullary  motor  nuclei,  producing  bulbar  paralysis  {see  Bulbar 
Palsy).  In  nine  tenths  of  the  cases  the. muscles  of  the  upper  limbs  are  attacked 
earliest,  especially  the  intrinsic  muscles  of  the  hand.  Sclerosis  of  the  pyramidal 
tracts,  which  frequently  accompanies  the  anterior  cornual  lesions,  is  evidenced 
by  increase  of  the  deep  reflexes,  especially  in  the  lower  limbs,  and  by  the  develop- 
ment of  an  extensor  type  of  plantar  reflex.  The  malady  is  usually  progressive, 
but  sometimes  it  becomes  arrested.  The  chief  dangers  to  hfe  arise  when  the 
respiratory  muscles  are  affected,  or  when,  from  bulbar  palsy,  deglutition  is  ren- 
dered difficult ;  in  such  cases,  not  only  does  malnutrition  result,  but  there  is  a 
risk  of  inhalation-pneumonia.  In  cases  which  become  arrested  as  a  result  of 
treatment,  the  atrophied  muscles  do  not  recover  ;  there  is  simply  a  halt  in  the 
advance  of  the  symptoms.  The  prospects  of  such  arrest  are  improved  by 
systematic  hypodermic  administration  of  strychnine,  beginning  with  Jg-  gr. 
daily,  and  quickly  increasing  to  Jg-  gr.  and  -^j  gr.  according  to  the  regime  laid 
down  by  Gowers,  which  should  be  persevered  with  for  raany  months.  Electrical 
treatment  does  not  appear  to  affect  the  progress  of  the  disease  materially,  but 
sometimes  ;ir-ray  treatment  over  the  medulla,  in  cases  of  bulbar  palsy,  has 
apparently  brought  the  degenerative  process  to  a  standstill. 

The  muscular  atrophy  of  acute  anterior  poUomyelitis  is  referred  to  in  the 
article  on  Infantile  Paralysis.  Purves  Stewart. 

MYASTHENIA  GRAVIS. — There  are  few  diseases  in  which  it  is  more  difficult 
to  form  an  accurate  prognosis  in  an  individual  case  than  in  myasthenia  gravis. 
Once  the  disease  has  been  recognized  by  the  presence  of  the  characteristic  and 
transient  fatigue  of  certain  groups  of  muscles,  especially  the  ocular,  facial, 
masticatory,  palatal,  laryngeal,  pharyngeal,  and  tongue  muscles,  the  large 
proximal  muscles  of  the  limbs  and,  most  dangerous  of  all,  the  respiratory  muscles, 
— once  these  phenomena  have  become  established,  the  outlook  is  grave.  Some 
cases  have  been  known  to  end  fatally  within  a  few  weeks ;  others  again,  with 
symptoms  apparently  no  less  severe,  have  survived  for  five  or  ten  years,  or  even 
longer.  Spontaneous  remissions  not  infrequently  occur  if  the  patient  leads  a 
quiet  life,  free  from  physical  exertion.  Hard  manual  labour,  or  physical  effort 
of  any  sort,  aggravates  the  symptoms.  The  im.mediate  cause  of  death  is  generally 
an  attack  of  fatigue  of  the  respiratory  rauscles.  Sometimes  individual  attacks 
of  this  sort  may,  for  the  time,  be  tided  over  by  means  of  artificial  respiration, 
combined  with  oxygen  inhalations.  Every  myasthenic  patient  ought  to  have  a 
cyUnder  of  oxygen  at  hand,  with  the  necessary  tubing  attached,  ready  for  such 
an  emergency.  Fatigue  of  the  muscles  of  deglutition  may  cause  attacks  of 
choking,  and  is  another  sign  of  serious  significance.  Purves  Stewart. 


MYOCARDIUM,     PRIMARY     DISEASE     OF  349 

^  MYCOSIS  FUNGOIDES. — This  rare,  but  dangerous,  skin  disease  shows  two 
stages  :  there  is  first  an  itching  erythematous  rash,  which  may  last  for  years  ; 
then  f ungating  tumours  form  in  the  skin  and  become  numerous  and  widespread. 
There  is  always  great  pruritus.  The  tumours  have  been  compared  to  a  tomato 
in  appearance. 

After  a  long  course  the  disease  ends  fatally,  the  patient  being  carried  off  at 
last  by  sepsis  and  exhaustion.  Occasionally  metastases  appear  internally.  A 
few  cases  have  been  reported  as  having  been  cured  by  x-ray  treatment. 

Reference. — Sequeira  and  others,  Proc.  Roy.  Soc.  Med.,  Dermatol.  Sect.,  1914. 

A.  Rendle  Short. 
MYELOID  SARCOMA.— (See  Bone  Tumours.) 

MYOCARDIUM,  PRIMARY  DISEASE  OF.— To  say  that  the  outlook 
in  any  case  of  valvular  disease  depends  ultimately  on  the  state  of  the  cardiac 
muscle  is  to  utter  an  obvious  platitude.  Yet  there  are  degrees  in  the  paramount 
importance  of  the  myocardium.  In  the  kind  of  case  that  is  usually  described 
as  one  of  chronic  valvular  disease,  the  two  factors  to  be  assessed  are  the  amount 
of  extra  work  imposed  on  the  myocardium  by  the  valvular  lesions,  and  the  fitness 
or  unfitness  of  the  myocardium  to  meet  that  extra  demand.  On  the  other  hand, 
there  is  a  group  of  cardiac  lesions  that  attack  the  musculature  of  the  heart 
directly  and  immediately,  either  with  or  without  a  simultaneous  injury  to  the 
valves  and  other  accessories  of  the  cardiac  mechanism.  In  such  cases  the 
prognosis  will  have  to  be  calculated  in  respect  of  two  factors  :  (i)  The  course 
usually  followed  by  the  morbid  process  at  work  in  that  particular  case ;  and 
(2)  The  nature  and  extent  of  the  injury  to  function  discernible  at  the  time  of 
examination. 

I. — Prognosis    according    to    the    Particular 
Morbid    Process    Present. 

The  primary  diseases  of  the  cardiac  muscle  maybe  (i)  Acute,  or  (2)  Chronic. 
Those  which  constitute  the  former  group  are  for  the  most  part  infective. 

I.  Acute  Infections  of  the  Cardiac  Muscle. — There  are  four  acute  infections 
in  which  myocardial  lesions  play  a  predominant  part  :  diphtheria,  rheumatic 
infection,  typhoid  fever,  and  influenza.  Of  these  the  rheumatic  infection  is 
the  only  one  in  which  the  valves  and  pericardium  are  also  attacked  ;  and  even 
here,  these  lesions  do  not  attain  to  such  a  pitch  of  intensity  during  the  active 
phase  of  the  rheumatic  process  as  to  share  prognostic  importance  equally  with 
the  damage  which  has  been  inflicted  directly  upon  the  myocardium  by  the 
infection. 

In  diphtheria,  it  would  appear  that  about  25  per  cent  of  all  the  deaths  are  due 
chiefly  or  solely  to  cardiac  failure.  In  other  words,  if  the  average  mortality  of 
this  disease  be  reckoned  at  10  per  cent,  there  is  a  chance  that  one  person  out  of 
every  25  attacked  by  diphtheria  will  die  of  cardiac  failure.  Sudden  syncope 
is  fairly  frequent  in  cases  carelessly  treated.  It  is  quite  impossible  to  assess 
in  figures  the  effect  of  antitoxin  treatment  in  reducing  these  risks,  but  it  is 
tolerably  certain  that  the  risk  of  cardiac  failure  is  directly  proportional  to  the 
intensity  of  the  infection  itself  ;  and  since  nothing  is  so  potent  as  antitoxin  in 
combating  the  virulence  of  the  infective  process,  it  follows  that  one  of  the  chief 
benefits  of  the  treatment  lies  in  the  fact  that  it  interposes  a  kind  of  barrier  be- 
tween the  infected  mucosa  and  the  susceptible  tissues  of  the  cardiac  wall.  This  is 
borne  out  by  the  fact  that  serious  and  fatal  cardiac  phenomena  are  much  more 
often  encountered  in  cases  of  diphtheria  where  antitoxin  treatment  has  been 


350  INDEX     OF     PROGNOSIS 

delayed  than  in  those  treated  early.  One  other  point  that  is  of  the  highest 
import  in  the  prevention  of  cardiac  failure  is  the  absolute  necessity  for  care  in 
regard  to  convalescence.  A  very  large  fraction  of  the  fatal  attacks  of  syncope 
occur  during  convalescence,  after  the  severity  of  the  infective  process  has  died 
down.  The  patient  is  allowed  to  sit  up  too  soon,  and  falls  back  dead.  This 
calamity — one  of  the  most  distressing  of  experiences  for  the  medical  attendant 
as  well  as  for  the  relations — can  be  averted  by  ordinary  precautions  :  convales- 
cence must  be  prolonged,  and  the  patient  should  be  allowed  to  sit  up  by  degrees 
only,  one  pillow  at  a  time.  It  is  especially  important  to  realize  that  the  condition 
of  the  patient  immediately  before  such  catastrophes  have  occurred  has  failed 
to  give  any  forewarning  of  approaching  danger,  so  that  these  precautions  must 
be  observed  even  in  cases  that  are  following  a  relatively  favourable  course. 

Acute  rheumatic  carditis  is  dealt  with  under  a  separate  heading  {see  p.  447). 

In  typhoid  fever,  the  cardiac  factor  is  probably  of  more  importance  than  appears 
on  the  surface.  It  is,  however,  obscured  by  the  nervous  and  other  evidences 
of  toxaemia  ;  and  it  is  so  unusual  to  encounter  cases  in  which  the  chief  clinical 
features  are  cardiac  that  these  may  be  dismissed  with  the  remark  that  sudden 
death  occurs  in  a  few  cases  of  typhoid  fever,  but  that  the  cardiac  origin  of  such 
calamities  is  not  definitely  proved.  Persistent  cardiac  disabiUty  following 
typhoid  fever  is  a  neghgible  quantity. 

True  influenza  is  a  rare  disease  in  this  country  at  the  present  time.  Cardiac 
complications  are  very  important,  both  in  relation  to  the  possibilities  of  a  fatal 
termination,  and  also  to  the  duration  of  the  period  of  disability  which  is  so 
apt  to  follow  this  disease.  Sudden  death  has  been  known  to  occur,  but  it  is 
excessively  rare.  On  the  other  hand,  persons  whose  cardiac  musculature  was 
damaged  by  arteriosclerotic  or  other  lesions  before  the  attack,  are  apt  to  find 
that  influenza  leaves  them  more  conscious  of  cardiac  disability  than  they  were 
before  the  illness.  Even  those  whose  hearts  were  sound  before  the  attack  are 
often  left  with  minor  evidences  of  cardiac  enfeeblement ;  these  symptoms  usually 
pass  off  in  the  course  of  a  few  weeks,  provided  ordinary  care  as  to  work  and  rest 
is  exercised. 

In  other  infections,  such  as  lobar  pneumonia,  scarlet  fever,  and  so  on,  symptoms 
and  signs  of  myocarditis  are  often  manifest ;  but  it  is  only  as  part  of  the  general 
picture,  the  phenomena  are  mild  as  a  rule,  and  death  is  never  or  almost  never 
due  to  cardiac  complications  alone. 

2.  Progressive  Degenerations  of  the  Myocardium. — Here  there  is  often  an 
overlapping  of  etiological  factors.  For  instance,  you  are  consulted  by  a  man 
with  thick,  contorted  arteries,  with  a  history  of  syphilis  and  signs  of  alcohoUsm. 
His  cardiac  enfeeblement  is  probably  due  in  some  measure  to  aU  three  factors  ; 
but  in  what  measure  to  any  particular  one  ?  So  far  as  prognosis  is  concerned, 
the  difficulty  is  to  some  extent  mitigated  by  the  fact  that,  whatever  the  cause 
may  be,  it  is  always  possible  to  discover  the  state  of  the  cardiac  functions,  and 
this  is  after  aU  more  important  than  precise  knowledge  as  to  the  nature  of  the 
morbid  processes  which  are  playing  havoc  with  those  functions.  Yet  in  making 
a  forecast  in  disease,  it  is  necessary  to  know  not  only  where  we  stand  at  the  time 
of  examination,  but  also  what  further  progress  along  the  downward  path  is 
to  be  expected.  It  is  therefore  imperative  to  make  full  inquiry  into  the  causes 
in  any  given  case  of  chronic  myocardial  degeneration. 

Of  all  the  various  factors,  none  is  more  serious  than  chronic  alcoholism.  The 
writer  has  found  that  it  is  always  wise  to  treat  with  the  utmost  respect  any  case 
of  chronic  myocardial  disease  in  which  there  is  reason  to  suppose  that  the  tissues 
have  been  long  subjected  to  the  deleterious  effects  of  alcoholism.  In  many  of 
these  cases  the  serious  nature  of  the  myocardial  disorder  is  plain  to  see,  for  the 


MYOCARDIUM,     PRIMARY    DISEASE     OF  351 


symptoms  afford  the  clearest  possible  indications  of  failing  contractility  ;  but 
even  where  this  is  not  so,  and  the  functions  are  not  badly  deranged,  the  fact 
that  the  patient  has  been  in  the  habit  of  alcoholic  excess  bodes  ill  for  his  heart's 
chance  of  surmounting  the  tasks  that  lie  ahead  of  it.  Not  only  so,  but  there  is 
this  further  disadvantage  about  the  effect  of  long-continued  alcoholic  intemper- 
ance on  the  heart,  that  it  persists  after  the  cause  has  been  removed.  Or  perhaps 
one  can  express  it  better  in  this  way,  that  a  man  who  has  been  alcoholic  up  to 
forty  and  abstemious  since,  will  tend  to  run  a  quicker  downward  course  if  at  the 
age  of  fifty  he  begins  to  manifest  evidences  of  cardiosclerosis.  It  is  nevertheless 
true  that  withdrawal  of  alcohol  in  any  such  case  will  affect  the  outlook  favourably, 
the  more  definitely  so  if  the  cardiac  symptoms  are  as  yet  trivial. 

Another  fact  of  ominous  significance  in  a  case  of  progressive  myocardial 
degeneration  is  a  history  or  other  evidence  of  syphilitic  infection.  This  matter 
is  more  fully  discussed  under  a  separate  heading  {see  Cardiac  Syphilis)  ;  here 
it  is  enough  to  say  that  in  any  case  of  myofibrosis  cordis  it  is  the  practitioner's 
duty  to  seek  by  every  possible  means  for  evidences  of  a  luetic  factor.  This  is 
particularly  to  be  suspected  in  cases  where  the  symptoms  are  severe  and  the 
physical  signs  disproportionately  slight.  Whenever  there  is  reason  to  believe 
that  the  myocardial  disease  is  in  part  due  to  syphilis,  the  prognosis  is  much 
graver  than  in  an  ordinary  straightforward  case  of  senile  heart.  This  is  true 
even  of  those  cases  in  which  there  are  none  of  the  aortic  lesions  that  constitute 
so  characteristic  a  feature  of  cardiac  syphilis.  About  50  per  cent  of  cardiac 
syphilitics  die  suddenly. 

The  other  factors  which  should  be  looked  for  in  a  case  of  the  kind  are  those 
which  injure  the  myocardium  through  the  arterial  lesions  that  they  imitate. 

Of  these,  mere  senility  is  the  least  grave.  Many  an  elderly  man  shows  signs 
of  cardiac  decay  which  have  developed  so  slowly  that  the  corresponding  symptoms 
are  scarcely  perceived  by  the  patient  himself.  He  has  to  take  his  hills  a  little 
more  deUberately  than  he  used  to  do,  but  this  gives  no  anxiety,  since  he  regards 
it  as  one  of  the  penalties  of  advancing  years.  Such  a  man  should  be  told  no 
more  than  this,  that  his  heart  is  not  so  young  as  it  was,  and  that  he  must  be 
content  to  accept  his  breathlessness  as  an  automatic  index  of  the  line  separating 
what  he  may  from  what  he  maj'^  not  undertake.  That  same  growing  old  which 
is  responsible  for  the  signs  at  the  time  of  examination  is  not  likely  to  accelerate 
unless  there  be  some  definite  force,  over  and  above  that  of  mere  senescence,  at 
work  upon  his  arteries. 

Of  the  various  types  of  overstress  to  which  the  heart  is  exposed,  continuous 
emotional  strain  appears  to  be  the  most  universally  deleterious.  The  exact 
manner  of  its  action  is  not  understood,  but  no  one  who  has  seen  many  cases  of 
cardiosclerosis  wiU  fail  to  recall  examples  of  business  or  family  worry  accelera- 
ting the  final  debacle. 

The  importance  of  physical  strain  as  a  factor  in  the  causation  of  myocardial 
degeneration  is  a  debatable  point.  One  thing  at  least  is  clear,  that  overstress 
of  a  senile  heart  is  hable  to  dire  consequences  much  more  often  than  an  even 
greater  burdening  of  the  adolescent  or  j^outhful  heart.  Mitchell  Bruce's 
Lumleian  Lectures,  delivered  in  1911,  contain  a  great  deal  of  very  useful  infor- 
mation as  to  prognosis  in  cardiovascular  degeneration.  In  the  cases  which 
supply  the  fundamentals  of  his  discourse,  he  found  that  cardiac  overstrain  in 
the  young  and  healthy  did  not  shorten  life  much,  if  at  all,  for  the  average  duration 
of  life  after  the  strain  was  34  years,  and  the  average  age  at  death  66  years. 

Of  other  factors,  high  arterial  tension  is  one  of  the  most  serious.  A  majority 
of  such  cases  end  in  cardiac  failure.  There  are  three  points  to  bear  in  mind  in 
constructing  a  prognosis  here,     (i)   If  the  hyperpiesis  be  attributable  to  some 


352  INDEX     OF     PROGNOSIS 

provocative  factor  that  can  be  checked,  so  much  the  better  for  the  patient ; 
where  it  is  due  to  something ,  such  as  manifest  renal  disease,  that  we  can  do 
Uttle  to  mitigate,  the  outlook  is  bad.  (2)  The  actual  height  of  the  pressure 
matters  less  than  its  course.  Other  things  being  equal,  a  rising  tension  is  bad ; 
it  means  an  increase  of  the  cardiac  burden.  Fall  in  the  pressure  is  also  a  bad 
sign  if  it  be  accompanied  by  evidences  of  increasing  cardiac  inadequacy  ;  it 
proves  that  the  heart  is  faihng  in  its  prime  duty,  that  of  maintaining  a  steady 
supply  of  blood  to  the  peripheral  organs  and  tissues.  (3)  And  this  is  merely 
another  way  of  sajdng  that  a  high  pressure  is  not  necessarily  a  sign  of  evil  omen — 
the  fact  that  treatment  fails  to  bring  down  a  raised  tension  is  not  in  itself  to  be 
deprecated  in  every  case.  AU  the  organs,  including  the  myocardium  itself, 
depend  on  the  maintenance  of  a  steady  blood-pressure  for  their  nutrition  ;  and 
it  is  probable  that  in  many  cases  a  high  pressure  is  essential  to  the  sustenance 
of  the  cardiac  muscle  and  its  functions. 

Bruce,  in  the  lectures  already  referred  to,  separates  a  '  metabolic  '  group  of 
cardiosclerotic  subjects — obese,  self-indulgent  persons,  with  sugar  and  usually 
albumin  in  the  urine.  The  cardiac  phenomena  of  such  patients  tend  to  run  a 
benign  course,  particularly  if  the  bad  ways  of  Uving  be  not  incorrigible.  The 
average  period  elapsing  between  the  onset  of  cardiac  symptoms  and  the  patient's 
death  was  I2|^  years  in  Bruce's  cases  ;  one  patient  lived  for  32  years  after  the 
onset  of  symptoms.  Of  course  it  is  necessary  to  recollect  in  this,  as  in  renal 
cases,  the  possibihties  of  death  from  some  non-cardiac  cause  such  as  uraemia 
or  acid  intoxication. 

A  gouty  element  in  the  case  is  not  in  the  patient's  disfavour. 

On  the  other  hand,  a  strong  family  history  of  cardio-arterial  degeneration  must 
be  reckoned  as  an  unhappy  feature  of  the  case. 

In  the  very  obese  it  is  common  to  encounter  symptoms  and  signs  indicative 
of  myocardial  inadequacy,  and  these  are  not  to  be  under-rated.  They  point  to 
an  overloading  of  the  subpericardial  interstices  with  fat,  which  often  infiltrates 
the  muscle  itself  along  its  connective-tissue  planes,  crushing  and  starving  the 
muscular  fibres.  Patients  in  this  state  are  therefore  iU  prepared  to  cope  with 
the  emergencies  of  hfe  ;  they  fail  with  undue  ease  in  the  presence  of  acute  disease, 
particularly  bronchitis  and  pneumonia. 

Two  other  factors  remain  for  consideration — the  patient's  temperament  and 
his  circumstances.  The  worrying,  splenetic  individual  makes  a  bad  cardiac 
patient,  and  so  does  the  man  whose  affairs  are  hard  to  escape  from  ;  and  the 
combination  of  the  two,  sometimes  encountered  in  successful,  pushing  business 
or  professional  men,  is  particularly  deadly.  To  such  persons  the  inevitable 
advice — "  Eat,  drink,  and  smoke  sparingly,  work  moderately,  and  worry  not  at 
all  " — too  often  appears  so  impossible  of  accomplishment  that  it  is  disregarded, 
and  downfall  ensues. 

So  much  for  the  place  of  etiology  in  the  prognosis  of  myocardial  disease. 

II. — Influence  of  the  Nature  and  Amount  of  Functional  Injury 
SHOWN  at  Examination. 

We  must  next  consider  the  relative  importance  of  symptoms  and  physical  signs, 
and  in  order  to  arrive  at  a  proper  understanding  of  their  significance  it  is  essential 
to  reahze  they  are  merely  means  to  an  end — the  assessment  of  the  capacity  of 
the  cardiac  muscle  to  do  its  work.  Now,  the  chief  end  of  the  myocardial  tissues 
lies  in  the  ventricular  contractions  ;  it  is  to  perform  this  task  that  the  heart 
exists.  Therefore  the  gravest  features  of  myocardial  disease  are  those  which 
point  to  impairment  of  the  contractility  of  the  ventricles.  Whatever  the  cause 
of  the  trouble,  this  holds  good. 


MYOCARDIUM,     PRIMARY    DISEASE     OF  353 

Impairment  of  Contractility  of  Ventricles. — We  come  here  to  a  fact  that  has 
not  yet  received  all  the  attention  which  it  deserves,  despite  all  the  teachings 
of  the  past  twenty  years  :  the  fact  that  symptoms  afford  a  more  reliable  basis 
for  the  estimation  of  ventricular  contractility  than  physical  signs. 

First  among  these  symptoms  is  breathlessness.  Often  it  is  the  first  to  be 
noticed,  and  the  ease  with  which  it  is  evoked  constitutes  an  excellent  gauge  of 
the  state  of  the  ventricular  wall.  At  first  it  is  only  noticed  when  the  patient 
puts  himself  to  some  unusual  exertion,  such  as  climbing  a  hill  or  hurrying  to 
catch  a  train.  By  degrees  his  field  of  cardiac  response,  to  borrow  Mackenzie's 
phrase,  becomes  more  and  more  limited,  till  walking  on  the  flat  becomes  a 
difficult  task.  Other  things  being  equal,  the  more  readily  the  patient's  breath 
fails,  the  worse  the  prognosis. 

There  are  also  various  forms  and  degrees  of  paroxysmal  dyspnoea,  the  signifi- 
cance of  which  is  important  in  respect  of  prognosis.  When  a  person  with 
myocardial  disease  develops  Cheyne-Stokes  breathing,  it  does  not  of  necessity 
forebode  evil.  For  example,  an  elderly  man  with  elderly  arteries  and  some 
cardiac  enlargement  is  found  to  exhibit  Cheyne-Stokes  breathing  during  sleep  : 
here  it  is  of  little  significance  unless  other  signs  of  contractile  failure  begin  to  be 
manifest  or  the  respiratory  periodicity  itself  become  rapidly  more  and  more 
definite.  Grouping  of  the  respiratory  movements  is  of  importance  only  when 
it  is  one  of  a  group  of  symptoms  suggesting  gradual  shrinkage  of  ventricular 
contractility.  When  we  come  to  an  aggravated  degree  of  the  same  kind  of 
phenomenon,  however — to  the  various  forms  of  periodic  dyspnoea  with  subjective 
distress  which  are  grouped  together  within  the  term  '  cardiac  asthma  ' — a  graver 
condition  is  encountered.  If  a  patient  with  chronic  myocardial  disease  begins 
to  be  afflicted  with  attacks  of  respiratory  distress,  coming  on  chiefly  at  night, 
this  is  in  and  by  itself  a  sign  of  impairment  of  the  contractile  power  of  the 
ventricle.  It  appears  from  recent  work  by  Lewis  and  others  that  the  actual 
cause  of  this  type  of  dyspnoea  is  an  acidosis  dependent  on  deficient  oxygenation 
of  the  blood.  To  accept  this  explanation  affords  a  basis  for  the  indubitable  fact 
that  the  more  extreme  the  dyspnoea  the  worse  the  prognosis.  The  writer  has 
observed  cases  of  chronic  myocardial  disease  in  which  the  approach  of  the  end 
has  been  foreshadowed  by  the  development  of  a  periodic  dyspnoea  more  or  less 
continuous,  and  amounting  in  its  intensity  to  a  veritable  air-hunger,  in  association 
with  other  evidences  of  acidosis — ethereal  smell  in  the  breath,  vomiting  and 
diarrhoea,  delirium,  and  other  nervous  symptoms.  As  part  of  such  a  syndrome 
as  this,  the  periodic  breathlessness  is  as  grave  a  feature  as  can  be.  Where  heart- 
block  is  present,  various  degrees  of  grouped  disturbance  of  the  respiratory 
rhythm  may  occur  ;  these  are  usually  proportional  to  the  degree  of  block  present, 
and  do  not  therefore  furnish  any  index  of  the  amount  of  impairment  of 
contractility. 

The  significance  of  cardiac  pain  as  a  sign  of  defective  contractile  power  has 
beeA  fully  considered  under  the  heading  of  Angina  Pectoris,  so  that  httle  time 
need  be  devoted  to  it  here.  Suffice  it  to  say  that  the  appearance  of  cardiac  pain 
in  any  case  of  myocardial  disease,  whether  the  lesion  be  acute  or  chronic,  is 
always  a  serious  matter,  because  it  portends  inadequacy  of  the  ventricles'  power 
to  contract.  The  actual  importance  of  pain  as  a  quantitative  index  of  contractile 
failure  is  conditional  on  several  considerations.  First,  how  easily  is  it  provoked  ? 
Second,  how  easily  is  it  relieved,  particularly  by  vasodilators  ?  Third,  what 
other  evidence  is  there  of  myocardial  disease  ?  Fourth,  how  severe  is  the  pain  ? 
The  order  of  these  questions  is  roughly  that  of  their  relativd  importance.  Angina 
must  always  be  regarded  as  a  symptom  and  not  a  disease,  significant  from  the 
prognostic  standpoint  not  for  its  own  sake  but  by  virtue  of  that  which  it  reveals. 


354  INDEX     OF    PROGNOSIS 

A  symptom  which  is  held  in  great  awe  by  the  pubhc  as  evidence  of  cardiac 
danger  is  the  liability  to  faint.  Now  this  view  is  certainly  not  supported  by 
clinical  experience,  which  shows  that  this  particular  symptom,  so  far  from  being 
an  important  sign  of  myocardial  decadence,  is  rarely  associated  with  cardiac 
disease  at  all.  It  is  true  that  a  man  seized  with  an  anginal  attack  will  often 
faint  as  a  result  of  the  pain  which  he  endures,  and  that  the  myocardial  patient 
may  die  suddenly  :  but  apart  from  these  two  catastrophic  types  of  faint,  which 
are  seldom  foreshadowed  by  less  minatory  degrees  of  syncope,  the  cardiac  patient 
is  little  if  at  all  more  prone  to  faint  than  the  ordinary  individual.  The  fainting 
attacks  of  children,  which  have  so  often  led  to  an  unfortunate  statement  about 
a  weak  heart,  are  nearly  always  attacks  of  minor  epilepsy,  and  have  nothing 
whatever  to  do  with  heart  disease. 

Dropsy  is  an  accurate  index  of  impairment  of  contractihty  in  disease  of  the 
myocardium,  but  it  takes  a  little  time  to  develop,  so  that  it  is  seldom  in  evidence 
in  acute  myocarditis.  But  in  the  chronic  degenerations  of  the  cardiac  muscle 
it  is  an  almost  constant  feature,  in  the  later  stages  if  not  before.  Its  value  as  an 
indicator  of  failing  contractile  force  is  to  be  found  by  a  consideration  of  the 
extent  and  depth  of  the  oedema,  its  rate  of  development,  and  its  behaviour  under 
the  influence  of  rest  and  other  therapeutic  measures.  In  this  connection  it  is 
well  to  remember  two  things.  First,  nothing  but  actual  personal  examination 
of  the  patient's  ankles  should  suffice  to  convince  one  as  to  the  presence  or  absence 
of  oedema  ;  and  second,  the  word  '  dropsy  '  is  very  alarming  to  many  patients, 
and  should  therefore  be  avoided  as  far  as  possible.  There  are  also  two  fairly 
obvious  precautions  to  observe  before  attributing  cEdema  of  the  legs  to  cardiac 
disease.  First,  every  means  must  be  used  to  assure  oneself  that  it  is  not  a  renal 
dropsy,  and  this  should  comprehend  thorough  examination  of  the  urine,  including 
microscopic  examination  of  the  centrifuged  deposit.  Second,  the  possibihty 
of  some  associated  cause  of  oedema,  such  as  varicose  veins  or  fibroids  of  the 
uterus,  should  not  be  forgotten.  Even  after  all  precaution  has  been  exercised, 
however,  it  is  sometimes  impossible  to  determine  whether  oedema  is  partly, 
mainly,  or  wholly  cardiac  ;  or  whether  it  does  perhaps  owe  its  origin  to  coincident 
renal  or  other  disease.  When  such  difficulties  arise,  the  importance  of  oedema 
as  a  quantitative  index  of  loss  of  contractihty  is  to  some  extent  discounted,  and 
we  must  be  content  to  assess  our  patient's  future  fortune  by  such  other  means 
as  are  at  our  disposal. 

The  daily  output  of  urine  shrinks  with  failure  of  contractility,  and  increases 
again  under  successful  treatment.  Whenever  possible  this  must  be  accurately 
measured  and  charted.  There  are  few  symptoms  of  more  definite  prognostic 
value  than  this  in  cases  of  myocardial  disease  that  have  reached  the  stage  at 
which  rest  in  bed  and  continuous  observation  are  necessar5^ 

A  symptom  which  may  appear  near  the  end,  especially  in  cases  of  acute 
myocardial  damage,  is  vomiting  ;  it  is  not  uncommon  in  the  severe  forms  of 
cardiac  rheumatism  and  diphtheria.  In  such  cases  it  is  nearly  always  associated 
with  other  evidences  of  approaching  cardiac  failure,  and  is  a  sign  of  the  very 
gravest  significance.  In  diphtheria,  the  children  who  vomit  usually  suffer  from 
epigastric  pain,  and  display  a  bruit  de  galop,  the  majority  dying  within  two  or 
three  weeks  of  the  onset. 

The  pulse  furnishes  two  useful  indications  of  contractile  failure.  The  alternating 
pulse  and  its  prognostic  import  are  discussed  in  the  article  on  Pulse,  Irregu- 
larities OF,  but  here  its  paramount  importance  as  a  sign  of  failing  contractility 
must  be  insisted  on.  Although  it  is  true  that  people  maj'^  live  for  years  after 
this  type  of  variation  has  been  first  noticed,  yet  it  is  always  a  mark  of  grave 
myocardial  degeneration.     The  other  pulse  change  which  argues  the  same  thing 


MYOCARDIUM,     PRIMARY     DISEASE     OF  355 

in  a  person  whose  heart  muscle  is  diseased  is  progressive  quickening.  If  there 
is  no  extrinsic  factor,  such  as  pyrexia,  to  explain  this  away,  it  is  an  ominous 
proof  of  increasing  incompetence  of  the  ventricular  wall  to  perform  those  vital 
duties  that  are  expected  of  it.  In  an  adult  with  myocardial  disease,  a  pulse 
running  persistently  at  over  120  per  minute  is  a  signal  of  immediate  danger. 

Among  the  physical  signs  indicative  of  contractile  failure,  there  are  two  that 
are  of  some  prognostic  value.  The  first  of  these  is  perhaps  seldom  appreciated 
at  its  true  value — weakening  of  the  cardiac  sounds.  In  acute  rheumatic  heart 
disease,  for  example,  it  is  almost  possible  to  measure  the  unhappy  progress  of 
the  myocardial  enfeeblement  by  the  softening  of  the  first  sound  at  the  apex  ; 
in  the  great  majority  of  the  cases  of  this  description  where  a  pericardial  rub  is 
or  has  been  heard,  weakening  of  the  first  sound  at  the  apex  is  a  sign  of  severe 
myocarditis,  and  not  of  pericardial  effusion.  In  the  other  acute  infections,  such 
as  typhoid  fever,  it  may  be  almost  the  only  indication  of  approaching  ventricular 
failure.  Of  course,  the  intensity  of  the  first  sound  varies  widely  according  to  the 
thickness  of  the  chest-wall  and  other  factors,  in  which  difierent  individuals 
difier  widely  from  each  other  ;  so  that  it  is  not  safe  merely  to  compare  the  heart 
sounds  of  any  one  person  with  an  imaginary  general  standard.  The  comparison 
should  rather  be  between  the  first  sound  at  the  apex  and  the  second  sound  at  the 
base  ;  or  between  the  sounds  as  heard  on  one  day  as  compared  with  their 
intensity  a  day  or  two  later.  At  the  same  time  it  is  legitimate,  and  indeed  highly 
necessary,  to  recognize  the  prime  importance  of  feeble  heart-sounds  in  a 
person  with  average  thoracic  walls,  in  a  case  of  myocardial  disease. 

The  appearance  of  the  gallop  rhythm  points  in  the  same  direction.  In  saying 
this  one  does  not  of  course  include  the  cases,  common  in  childhood,  in  which 
a  close  imitation  of  the  true  bruit  de  galop  is  produced  by  a  combination  of 
reduplication  of  the  second  sound  with  rapid  action  of  the  heart.  True  gallop 
rhythm  is  always  a  sign  of  ventricular  inadequacy,  one  of  those  valuable  hints 
which  must  be  interpreted  as  serious  even  when  there  is  little  collateral  evidence 
to  support  such  an  interpretation.  To  exemplify  this  point :  a  short  time  ago 
a  woman  came  into  the  writer's  out-patient  room  complaining  only  that  she 
felt  run  down.  Examination  of  the  chest  disclosed  the  presence  of  a  bruit  de 
galop,  and  the  urine  was  found  to  be  that  of  subacute  nephritis.  Chiefly  on 
the  strength  of  the  gallop  rhythm,  the  woman  was  strongly  urged  to  come  into 
the  hospital,  but  she  postponed  her  decision  ;  within  a  week  she  died  suddenly. 
And  this  sign  is  ominous  when  it  appears  in  cases  of  acute  infective  disease.  One 
does,  it  is  true,  come  across  cases  in  which  recovery  ensues  even  though  there 
has  been   a  gallop  rhythm  ;    but  such  are  the  exceptions. 

Finally,  certain  changes  in  the  lungs  portend  a  speedy  dissolution,  because 
they  are  also  evidence  of  waning  contractility.  Of  these,  two  stand  pre-eminent 
— acute  pulmonary  oedema  and  infarction  of  the  lung.  The  former  is  an  almost 
constant  feature  of  the  last  phase  in  cases  of  acute  rheumatic  carditis  doomed 
to  early  death.  Infarction  is  more  often  recovered  from  than  acute  oedema. 
Hydrothorax  is  also  a  bad  feature  of  a  case  of  chronic  myocardial  disease,  partly 
because  it  proves  a  weak  muscle,  and  partly  because  it  adds  a  new  embar- 
rassment to  the  act  of  respiration.  A  sign  of  approaching  cardiac  failure  to 
which  Mackenzie  has  drawn  attention  is  the  development  of  fine  crepitations 
at  the  bases.  This,  if  looked  for,  is  a  valuable  forewarning  of  difficulties,  which 
may  be  averted  by  timely  insistence  on  a  period  of  rest.  As  Morison  points 
out,  these  crepitations  appear  and  disappear  according  to  the  patient's  changes 
of  posture,  always  appearing  in  the  most  dependent  part  of  the  lung. 

All  these  phenomena  owe  their  serious  import  to  the  fact  that  they  arise  from 
impairment  of  the  contractile  force  of  the  ventricles,  the  very  thing  for  which 


356  INDEX     OF    PROGNOSIS 

the  heart  has  been  evolved  and  on  which  hfe  depends.  The  gravest  generalization 
that  can  be  made  about  any  case  of  primary  myocardial  disease  is  that  there  is 
evidence  of  failing  of  the  contractile  force  of  the  ventricles. 

Impairment  of  Tonus. — As  to  the  other  myocardial  functions,  it  may  seem  a 
splitting  of  straws  to  differentiate  between  contractility  and  tonus,  but  so  far 
as  prognosis  is  concerned  there  is  certainly  a  difference,  if  we  regard  as  signs  of 
lost  tone  the  appearance  of  a  systolic  murmur  of  mitral  incompetence,  and 
ventricular  dilatation.  Many  a  case  of  cardiosclerosis  in  which  there  are  most 
definite  and  threatening  signs  of  exhausted  contractility  goes  on  to  the  end  with 
little  or  no  dilatation.  Indeed,  in  such  cases  the  appearance  of  a  mitral  systolic 
murmur,  denoting  failure  of  tone  in  the  muscular  tissue  of  the  auriculo- ventricular 
ring,  may  be  attended  by  actual  relief  of  the  symptoms,  possibly  because  the 
overtaxed  ventricle  is  thus  freed  of  some  of  the  mass  of  blood  to  be  lifted  by 
each  systole.  Each  of  these  phenomena,  ventricular  dilatation  and  mitral 
incompetence,  demands  separate  and  detailed  consideration. 

The  important  aspect  of  dilatation,  so  far  as  prognosis  is  concerned,  is  its 
course  rather  than  its  extent.  Rapid  stretching  of  the  ventricle  in  acute  disease 
is  an  untoward  feature,  because  it  proves  that  the  muscle  is  thoroughly  saturated 
with  poison  ;  but  it  carries  no  immediate  threat  of  dissolution,  unless  there  are 
simultaneous  signs  of  impaired  contractility.  In  acute  rheumatic  carditis,  for 
instance,  it  is  remarkable  how  large  the  heart  may  become  without  remaining 
so  permanently  or  killing  the  patient.  Even  in  so  insidious  a  disease  as  cardio- 
sclerosis, acute  dilatation  may  prove  temporary,  though  of  course  this  is 
exceptional.  Generally  speaking,  the  more  rapid  the  enlargement  of  the  heart, 
the  worse  the  prognosis.  Again,  it  will  go  worse  with  the  patient  if  dilatation 
persists  in  spite  of  treatment,  for  two  reasons  :  because  it  argues  profound 
injury  to  the  cells  of  the  cardiac  wall,  and  because  a  permanent  increase  in  the 
cubic  content  of  the  ventricle  imposes  a  correspondingly  increased  burden  of 
blood  for  the  ventricle  to  lift  at  each  systole. 

As  to  the  mitral  systolic  murmur  that  so  often  makes  itself  heard  in  primarily 
muscular  cases  of  heart  disease,  there  can  be  no  question  that  in  such  it  owes 
its  origin  to  a  fall  in  the  tonicity  of  the  muscle  which  forms  part  of  the  mitral  ring. 
What,  then,  is  its  prognostic  significance  ?  It  is  remarkable  to  find  how  close 
an  agreement  there  is  as  to  its  unimportance — whether  in  the  chronic  or  in  the 
infective  lesions  of  the  myocardium — among  those  who  have  made  a  systematic 
study  of  the  point.  The  only  weight  it  can  be  said  to  carry  is  that  it  sometimes 
serves  to  confirm  a  diagnosis  of  heart  disease  that  would  otherwise  rest  on 
.•suspicion  only.  In  diphtheria.  White  and  Smith,  of  Boston,  U.S.A.,  who  made 
A  statistical  study  of  nearly  a  thousand  cases,  found  that  the  presence  of  a  systolic 
ibruit  at  the  apex  added  nothing  to  the  gravity  of  the  prognosis,  even  when  the 
iniurmur  persisted  long  into  convalescence.  Over  and  over  again  Mackenzie 
;and  other  systematic  writers  on  myocardial  decay  have  of  recent  years  insisted 
on  the  same  fact,  that  a  mitral  systolic  murmur  adds  nothing  to  the  gravity  of 
the  case.  Indeed,  the  sense  of  many  of  these  writings  is  to  the  effect  that 
patients  with  syphilitic,  atheromatous,  and  other  chronic  diseases  of  the  cardiac 
muscle  do  better  if  to  the  evidences  of  diminishing  contractile  power  there  be 
added  signs  of  ventricular  dilatation,  or  a  mitral  systolic  murmur,  or  both, 
than  if  the  case  be  marked  only  by  evidences  of  lessened  contractility.  It 
follows  from  this,  that  the  loudness  of  an  apical  bruit  is  no  criterion  of  the 
seriousness  of  the  case  :  except,  perhaps,  in  the  direction  opposite  to  that  which 
might  at  first  seem  obvious,  for  it  is  certainly  reassuring  to  discover  in  what 
looks  otherwise  like  a  very  severe  case,  say,  of  cardiac  diphtheria,  a  loud  murmur 
at  the  apex.     In  such  a  case  we  accept  it  as  welcome  proof  that  the  heart  still 


MYOCARDIUM,     PRIMARY     DISEASE     OF  357 


possesses  some  contractile  force.  Finally,  it  is  a  mistake  in  treatment  to  keep 
patients  in  bed  after  acute  illness  until  the  murmur  which  it  has  caused  has 
disappeared.  It  may  persist  for  weeks  or  months,  and  such  long  confinement 
to  bed  does  the  patient  far  more  harm  than  good. 

Disturbances  of  the  Other  Functions  of  the  Cardiac  Muscle. — The  rhythmic 
production  of  stimuli,  the  capacity  for  excitation  by  those  stimuli,  and  the 
function  of  conductivity  are  all  considered  fully  in  the  article  on  Pulse, 
Irregularity  of. 

There  are  two  types  of  irregularity  that  do  not  matter — sinus  irregularity 
and  extrasystoles — the  latter  being  so  common  in  cardiosclerosis  as  to  be  almost 
the  rule.  It  is  well  worth  while  to  realize  the  absolute  insignificance  of  the 
extrasystolic  type  of  arrhythmia  :  many  an  elderly  man  is  needlessly  and  indeed 
hurtfully  "  cabined,  cribbed,  confined  "  in  his  activities  by  a  medical  attendant 
who  is  frightened  by  discovering  that  the  pulse  is  irregular,  without  perceiving 
that  the  irregularity  is  of  the  unimportant  kind. 

Paroxysmal  tachycardia  has  rather  more  significance,  for  on  the  one  hand  it 
proves  the  existence  of  an  abnormally  irritable  focus  in  the  diseased  heart  wall, 
while  on  the  other  it  adds  the  burden  of  excessively  rapid  work  to  that  which 
the  imperfect  ventricular  muscle  can  barely  undertake.  This  extra  stress 
reveals  itself  during  the  attacks  in  several  ways  ;  the  heart  becomes  rapidly 
dilated,  the  legs  may  swell,  the  patient  is  cyanosed  and  distressed,  and  the  pulse 
may  even  become  alternating.  The  gravity  of  the  outlook  is  obviously  enhanced 
in  any  given  case  of  myocardial  disease  when  there  occur  paroxysms  of  tachy- 
cardia with  such  dire  effects  ;  and  their  serious  import  is  to  be  measured  in 
terms  of  the  readiness  with  which  each  attack  exhausts  the  heart.  Information 
as  to  this  is  yielded  by  observation  of  the  behaviour  of  the  heart  during  the 
paroxysm,  and  also  by  its  condition  after  the  attack  is  over. 

The  condition  of  auricular  flutter  is  transitional,  both  in  nature  and  importance, 
between  that  of  paroxysmal  tachycardia  and  that  of  auricular  fibrillation  ; 
probably  its  worst  possibility  is  that  it  may  pass  over  into  the  latter.  Fortunately 
it  seems  often  to  yield  to  digitalis. 

The  totally  irregular  pulse  of  auricular  fibrillation  is  always  an  unwelcome 
feature  of  myocardial  disease,  whether  acute  or  chronic.  It  means  that  the 
cardiac  muscle  has  reached  a  certain  point  in  its  downward  career,  from  which 
it  can  never  recover  permanently.  Patients  with  primary  muscle  disease  of  the 
heart  who  develop  this  type  of  arrhythmia  fare  worse  than  those  in  whom  it 
constitutes  a  late  phase  of  chronic  mitral  disease  ;  in  the  former,  the  ventricle 
is  less  able  to  cope  with  the  rapid  irregular  stimuli  handed  down  to  it  by  the 
auricle  than  in  the  latter,  for  the  cells  of  its  wall  are  already  barely  fit  to  carry 
on  their  systolic  task.  Much  depends  in  this,  as  in  auricular  flutter,  on  the 
response  of  the  heart  to  digitalis  treatment,  which  should  receive  a  proper  trial 
before  a  bad  prognosis  is  arrived  at  ;  if  a  course  of  full  doses  of  this  drug,  given 
under  suitable  conditions,  fails  to  relieve  the  dyspnoea  and  slow  the  pulse,  then 
the  prognosis  is  indeed  gloomy.  Hay  points  out  that  the  reaction  of  the  heart 
to  the  new  rhythm  (or  want  of  it)  should  be  observed  ;  by  this  means  some 
gauge  of  the  ventricle's  capacity  to  stand  the  strain  will  be  forthcoming.  He 
also  remarks  that  those  cases  in  which  the  irregularity  and  its  attendant 
disabilities  come  on  suddenly  and  without  premonition  do  worse  than  those  in 
which  the  onset  is  more  gradual.  The  majority  of  myocardial  decadents  do  not 
survive  the  onset  of  this   irregularity  for  more  than  three  years. 

The  presence  of  signs  of  interference  with  the  conduction  of  impulses  from  auricle 
to  ventricle  (lengthening  of  the  a-c  interval,  heart-block  of  various  grades)  adds 
to  the  severity  of  the  prognosis  ;    and  the  greater  the  degree  of  interference 


358  INDEX     OF    PROGNOSIS 

the  more  is  this  the  case.  The  presence  of  heart-block  in  any  case  of  cardiac 
disease  proves  that  there  is  a  gross  lesion  of  the  deep  myocardium.  In  acute 
infective  disease  this  block  nearly  always  turns  out  to  be  transient,  so  that  it 
does  not  -warrant  a  gloomy  view  of  the  case  on  its  own  account ;  but  in  the 
chronic  myocardial  degenerations  it  is  otherwise,  for  here  the  lesion  of  conduc- 
tivity is  nearly  always  progressive  or  at  least  permanent,  and  except  in  some 
syphilitic  cases,  it  is  not  influenced  by  treatment.  Even  so,  however,  an 
absolutely  bad  prognosis  is  not  warranted  ;  for  on  the  one  hand  the  heart-block 
may  interfere  but  little  with  the  efficient  emptying  of  the  ventricles  in  systole, 
while  on  the  other  there  is  always  just  a  chance  that  it  may  pass  off  after  an 
undeterminable  interval  and  reappear  no  more.  It  is  always  important  not  to 
allow  the  heart-block  to  make  one  forget  the  other  features  of  the  case  ;  for  the 
prognosis  depends  on  a  reasonable  consideration  of  the  state  of  all  the  cardiac 
functions,  and  the  influence  of  all  the  disturbances  encountered  on  the  power 
of  the  heart  to  carry  on  the  circulation  in  an  efficient  manner. 

The  Likelihood  of  Sudden  Death  in  primary  disease  of  the  myocardium 
depends  on  two  things.  It  may  occur  as  a  result  of  rupture  of  the  cardiac  wall 
or  gross  interference  with  a  part  of  the  myocardium  due  to  thrombosis  or 
embolism  ;  or  it  may  much  more  commonly  result  from  an  exhaustion  of  the 
contractile  power  of  the  ventricular  muscle.  We  are  forewarned  of  the  former 
type  of  possibility  by  pericardial  friction  or  rapid  enfeeblement  of  the  heart's 
action,  especially  if  it  follow  close  on  the  heels  of  an  anginal  attack.  Attacks 
of  this  kind — anginal  pain,  rapid  weakening  of  the  cardiac  sounds,  with 
pericardial  friction — occurring  in  cases  of  chronic  myocardial  disease,  warrant 
the  gravest  prognosis.  The  majority  of  such  cases  terminate  fatally  within  a 
few  days  ;  and  even  if  he  survive,  the  patient's  future  career  must  be  guarded 
with  the  utmost  care.  The  evidences  of  failing  contractile  power  have  been 
fully  described  above,  and  it  need  only  be  repeated  that  the  chief  end  of  the 
heart  is  to  contract  efficiently,  so  that  anything  which  suggests  an  encroachment 
on  this  function  is  a  grave  feature  of  the  case.  The  whole  art  of  prognosis  in 
heart  disease  lies  in  the  ability  of  the  physician  to  discover  whether  this  power 
is  threatened  or  not. 

The  Influence  of  Treatment  on  prognosis  is  unhappily  small,  apart  from  those 
points  that  have  already  been  mentioned  by  the  way.  It  is  no  use  flogging  a 
tired  horse,  and  not  much  good  can  be  derived  from  the  saturation  of  a  diseased 
myocardium  with  tonic  and  stimulant  drugs.  The  lines  along  which  most 
preservation  of  life  is  to  be  effected  in  these  cases  are  (i)  Grappling  with  the 
cause  ;   and  (2)  Saving  the  heart  from  overstress,  especially  of  the  sudden  type. 

Carey  F-  Coombs. 

MYOPATHIES. — [See  Muscular  Atrophies.) 

MYOSITIS  OSSIFICANS. — Two  conditions  pass  under  this  title,  the  one 
a  generalized  slow  ossification  of  muscles  all  over  the  body,  producing  a  so- 
called  '  brittle  man,'  and  the  other  a  newly  described  disease  in  which,  after 
a  fracture,  a  mass  of  bone  forms  in  the  neighbouring  muscles  owing  to 
dissemination  of  osteoblasts. 

Generalized  Myositis  Ossificans  is  rare,  lasts  many  years,  and  shows  alternate 
periods  of  advance  and  arrest.  It  always  ends  fatally,  lasting  about  ten  or 
twelve  years.  The  termination  is  usually  due  to  pulmonary  troubles  from 
fixation  of  the  chest. 

Traumatic  Myositis  Ossificans  has  only  come  into  prominence  since  the  intro- 
duction of  massage  and  movements  in  the  treatment  of  fractures,  and  the  use 
of  skiagraphy  for  diagnosis.     The  commonest  site  for  the  mass  of  bone  is  in 


NASAL     ACCESSORY     SINUSITIS 


359 


the  substance  of  the  brachiahs  anticus  after  an  injury  of  the  lower  end  of  the 
humerus  or  dislocation  of  the  elbow.  The  writer  has  seen  it  in  the  gastro- 
cnemius in  association  with  fracture  of  the  condyle  of  the  femur.  The  hard 
mass  in  the  muscle  can  be  moved  upon  the  underlying  bone.  It  usually  appears 
some  weeks  or  months  after  the  original  injury,  and  may  cause  severe  limitation 
of  movement. 

The  prognosis  depends  to  a  considerable  degree  on  the  treatment.  Early 
removal  by  operation  usually  leads  to  recurrence,  and  no  benefit  is  obtained. 
During  the  first  few  weeks  or  months,  absolute  fixation  with  a  plaster  case  or 
splint  appears  to  give  the  best  results.  After  the  ossification  is  complete  and 
the  bony  mass  has  settled  down,  it  may  be  removed,  but  not  until  several  months 
have  elapsed. 

Schulz  gives  the  German  Army  figures  for  the  years  1897-1907.  Ninety- 
nine  were  operated  on,  of  whom  26  per  cent  were  invahded  out  of  the  army ; 
313  were  treated  by  sphnts,  etc.,  of  whom  i6-6  per  cent  were  invaUded  out. 
It  must  be  remembered,  of  course,  in  comparing  these  figures,  that  naturally 
the  worst  cases  were  treated  by  operation. 

When  the  original  injury  affects  the  joint,  the  outlook  is  much  graver  than 
when  the  bone  was  broken.  Thus,  of  cases  operated  on  for  this  form  of  myositis 
ossificans  by  Chabrol,  there  were  95  bone  injury  cases,  of  which  77  were  cured, 
15  better,  3  no  better  ;  and  25  following  dislocation,  of  which  8  were  cured,  8 
better,  and  9  no  better.  It  will  be  wise,  therefore,  to  trust  to  rigid  fixation 
in  the  dislocation  cases. 

The  time  occupied  by  the  treatment  varies,  but  is  seldom  less  than  three 
months,  and  may  be  much  longer. 

Reference. — Lapointe,    Rev.  de  Chirurg.  1912,  657.  A.  Rendle  Short. 

NASAL  ACCESSORY  SINUSITIS.— The  risk  to  life  in  suppuration  of  the 
accessory  sinuses,  whether  acute  or  chronic,  is  only  slight.  In  more  than  25,000 
post-mortems,  such  suppuration  was  the  cause  of  18  deaths,  while  in  the  same 
series,  aural  suppuration  was  responsible  for  ten  times  that  number.^ 

Acute  cases  usually  resolve,  either  without  any  treatment,  or  with  minor 
operative  measures.  Such  resolution  may  be  delayed  for  weeks  or  months,  and 
then  take  place  without  operation. 

Measures  apphcable  to  all  sinuses,  both  with  and  without  operation,  are  the 
injection  of  vaccines  and  the  local  injection  of  bismuth  paste. 

Vaccine  Treatment. — In  acute  cases,  vaccines  are  usually  contra-indicated. 
The  following  results  were  obtained  in  chronic  cases  ;  in  the  majority,  however, 
some  operative  measure  was  also  employed. 

Results  of  Vaccine  Treatment  in  Chronic  Nasal  Accessory  Sinusitis. 


Reporter 


Harmer^ 
Logan  Turner^ 
Allen^  - 
Birkett* 
Levy*  - 
Patterson*  - 
Brawley* 


Cases  treated 


41 
5 
30 
4 
15 
11 
10 


Total 


116 


14 

2 
20 
0 
6 
1 
4 


47 

(or  40  per  cent) 


13 

(or  U  per  cent) 


36o  INDEX     OF     PROGNOSIS 

All  of  the  cases  reported  as  cured  had  been  recently  operated  upon,  so  that  it 
is  impossible  to  say  how  much  credit  should  be  given  to  the  vaccine. 

Vaccines  are  useless  as  a  substitute  for  operation.  They  may  be  of  some 
slight  help  afterwards,  but  even  this  is  not  certain. 

Bismuth  Paste. — Injections  of  this  paste  into  the  diseased  sinus,  as  advocated 
by  Beck,*  may  hasten  cure  after  operation,  but,  hke  vaccines,  they  are  not  a 
substitute  for  it. 

We  shall  now  proceed  to  consider  the  results  of  the  operative  treatment  of 
each  sinus  in  detail. 

Maxillary  Sinus. — The  majority  of  acute  cases  resolve,  even  without  treatment. 
Complications  are  rare,  and  fatalities  almost  unknown.  Treatment  consists  in 
the  washing  out  of  the  cavity  through  the  inferior  meatus  with  trocar  and 
cannula,  combined  with  the  application  of  vasoconstrictors  to  the  nasal  mucosa 
to  promote  drainage.  Cure,  in  a  really  acute  case,  is  almost  certain  under  treat- 
ment.    Chronic  cases  seldom,  if  ever,  recover  spontaneously. 

The  treatment  is  operative,  and  alternative  methods  are  :  (i)  Nasal  puncture 
and  lavage  through  trocar  and  cannula  ;  (2)  Alveolar  drainage  ;  (3)  Intranasal 
operation  (Claone)  ;  (4)  Radical  operation  through  the  canine  fossa  (Caldwell- 
Luc). 

1.  Nasal  puncture  and  lavage  through  trocar  and  cannula  is  an  unsatisfactory 
method  in  chronic  cases.  A  cure  can  sometimes  be  obtained,  but  only  if  the 
puncture  is  repeated  a  large  number  of  times.  Thus,  Koenig  and  Mahu®  record 
cases  cured  by  twenty-seven  and  fifty-four  punctures  respectively.  The  majority 
of  patients,  however,  would  object  to  so  many  repetitions  of  any  operation,  even 
if  very  slight. 

2.  Alveolar  drainage,  by  the  insertion  of  a  tube  through  a  perforated  tooth- 
socket,  with  subsequent  washing  out,  was  formerly  the  accepted  method.  A 
fair  proportion  of  cases  can  be  cured  by  this  means.  Tilley,'  out  of  27  cases, 
obtained  a  cure  in  only  5,  whilst  Logan  Turner*  records  cure  in  62  out  of  113 
cases,  a  total  percentage  of  47. 

3.  The  intranasal  operation  consists  in  making  a  large  opening  into  the  antrum 
through  the  inferior  meatus  of  the  nose.  The  results  are  better  than  those  of 
the  alveolar  operation.  Logan  Turner*  records  44  cures  in  55  cases  treated, 
Goning'  21  in  23,  Rethi^"  90  in  100,  and  Parker^^  12  in  15,  a  total  percentage  of 
cures  of  81.  Claone*,  the  originator  of  this  operation,  claims  that  it  vdW  cure 
80  per  cent  of  cases. 

4.  The  radical  canine  operation  consists  in  making  a  free  opening  into  the 
cavity  through  the  canine  fossa,  curetting  the  lining  membrane  if  necessary, 
and  then  making  a  free  opening  from  the  antrum  into  the  nose.  This  operation 
is  the  most  certain  in  its  results.  Tilley  gives  34  cures  out  of  37  cases,  and  Logan 
Turner*  12  out  of  12.  Cure  will  be  obtained  from  this  operation  in  something 
over  90  per  cent  of  cases.  Objections  to  it  are,  the  fact  of  its  being  a  more  severe 
operation  than  any  of  the  others,  the  occasional  post-operative  neuralgia  or 
anaesthesia  from  injury  to  the  infra-orbital  nerve,  and  the  anaesthesia  of  teeth 
froni  the  division  of  the  nerves  supplying  them. 

To  sum  up  :  Repeated  nasal  puncture  and  alveolar  drainage  are  unsuitable, 
the  former  because  of  its  uncertainty  and  necessity'  for  repetition,  the  latter 
because  a  cure  is  not  obtained  in  more  than  half  the  cases.  In  favour  of  the 
intranasal  operation  is  the  fact  that  it  is  a  slight  one,  and  can,  if  desired,  be 
performed  under  local  anaesthesia.  The  canine  operation  gives  a  better  chance 
of  cure  (over  90  instead  of  80  per  cent),  but  it  is  more  severe,  and  more  likely  to 
give  rise  to  troublesome  sequelae. 

Logan  Turner''^  has  shown  that  cases  with  an  excess  of  lymphocytes  in  the 


NASAL     ACCESSORY     SINUSITIS 


361 


discharge  are  more  resistant  to  treatment,  and  should  therefore  have  the  more 
radical  operation. 

Frontal  Sinus.- — Although  fatalities  are  rare,  they  occur  more  often  in  affec- 
tions of  this  sinus  than  of  any  other.  The  risks  are  either  an  intracranial 
infection  (abscess  or  meningitis),  or  infective  osteomyelitis  of  the  cranial  bones. 
Acute  cases,  in  the  absence  of  complications,  are  readily  cured  by  intranasal 
treatment.  Coagleyi^,  in  a  total  of  58  cases,  obtained  a  cure  by  intranasal 
methods  in  54,  or  93  per  cent  ;  2  cases  died,  or  3-4  per  cent.  This  is  probably 
a  higher  rate  of  mortality  than  the  normal,  only  the  more  severe  cases  getting 
to  the  specialist  for  treatment.  Chronic  cases  are  very  much  more  difficult  to 
cure  ;    but  the  mortality,  apart  from  operation,  is  very  slight. 

Treatment  is  operative,  and  the  alternatives  are  :  either  (i)  Intranasal 
methods  to  improve  drainage  and  allow  of  washing  out ;  or  (2)  One  of  the 
many  varieties  of  external  radical  operation. 

1.  The  intranasal  method  consists  in  a  partial  or  complete  removal  of  the 
middle  turbinal  bone,  and  opening  of  the  portion  of  the  ethmoidal  labyrinth 
which  is  in  relation  to  the  nasal  opening  of  the  sinus.  The  operation  has  only 
recently  been  used  to  any  large  extent.  Coagley,^*  from  an  experience  of  79 
cases,  records  14  per  cent  cured,  and  51  per  cent  improved.  Gruner^^  gives 
16  cures  out  of  18  cases.  Ingals,^^  from  an  experience  of  39  cases,  concludes 
that  a  cure  can  be  obtained  in  95  per  cent.  Watson  Williams^'  has  operated  on 
48  cases,  with  cures  in  about  50  per  cent,  and  i  death.  Tilley,^'  in  an  experience 
of  30  cases,  has  obtained  cure  or  relief  in  "  a  majority  of  them."  Thus,  the 
operative  mortality  in  these  216  cases  is  only  0-46  per  cent.  If  by  cure  is  meant 
freedom  from  all  discharge,  as  well  as  relief  from  symptoms,  it  is  only  obtained 
in  a  minority  of  cases.  Probably  from  50  to  75  per  cent  are  reheved  from  all 
troublesome  symptoms. 

2.  The  external  radical  operation,  as  exemplified  by  the  Killian  method, 
aims  at  obliteration  of  the  sinus.  It  was  performed  much  more  frequently  a 
few  years  ago  than  at  present. 

Results  of  External  Radical  Operation  for  Frontal  Sinusitis. 


Reporter 

Cases  treated 

Cured 

Improved 

Died 

Lindtis         .... 

Hornis 

Hosca!"         .... 
Watson  Williams"      - 
Marshik^^      .... 
Von  Eicken^ 

21 
28 

34 

28 

100 

11 

22 

32 
11 

8 
15 

1 

0 
2 
0 
3 
3 

Total 

265 

— 

— 

9 

(or  S'4  per  cent) 

Thus,  out  of  265  cases,  the  mortality  from  the  operation  was  3-4  per  cent. 
In  III  of  them  in  which  the  result  is  recorded,  a  cure  was  obtained  in  67  per  cent, 
and  improvement  in  26  per  cent.  In  addition  to  the  risk  to  life,  the  external 
operation  always  gives  rise  to  more  or  less  deformity,  and  may  be  followed  by 
complications.  Skillern,-  in  a  review  of  his  20  cases,  has  found  some  unpleasant 
after-results  in  nearly  all,  ranging  from  paralysis  of  the  upper  lid  and  anaesthesia 
of  the  forehead,  to  blindness  on  the  operated  side  from  injury  to  the  optic  nerve. 

To  sum  up  :  In  the  presence  of  such  complications  as  orbital  abscess,  the 
external  operation  is  essential.     In  other  cases,  the  intranasal  operation,  with 


362  INDEX     OF     PROGNOSIS 

a  mortality  of  about  0-5  per  cent,  will  relieve  symptoms  in  some  50  to  75  per  cent, 
and  has  no  unpleasant  sequelae.  The  radical  external  operation  has  a  mortality 
six  times  as  great,  gives  rise  to  deformity  and  other  complications,  but  will 
ensure  relief  or  cure  in  80  to  90  per  cent  of  cases. 

Ethmoidal  and  Sphenoidal  Sinuses. — Suppuration  of  either  sinus  may  cause 
death  by  meningeal  involvement  ;  or,  in  the  case  of  the  sphenoidal  sinus,  by  a 
septic  thrombosis  of  the  cavernous  sinus.  Either  event  is  rare,  but  StClair 
Thomson^*  has  collected  40  deaths  as  a  result  of  sphenoidal  sinusitis.  Both 
conditions  usually  occur  together  and  associated  with  suppuration  in  the  frontal 
sinus  and  antrum. 

A  cure  will  usually  result  when  the  cavities  are  freely  opened  intranasally  ; 
but,  in  the  case  of  the  ethmoidal  cells,  anatomical  conditions  sometimes  prevent 
this  being  satisfactorily  performed  without  undue  risk. 

References. — ^Treital,  Berlin  klin.  Woch.  li,  1139  ;  Wertheim,  Arch.  f.  Laryngol. 
Bd.  II  ;  Pitt,  Brit.  Med.  Jour.  1890,  i,  643  ;  *i7th  Int.  Cong.  Med.  191 3  ;  ^Bacterial 
Diseases  of  Respiration  ;  '^Laryngoscope,  igio  ;  ^Ibid.  ;  ''Rev.  Hebd.  de  Laryngol.  1906, 
April  ;  ''Jour,  of  Laryngol.  xix,  74  ;  ^Edin.  Med.  Jour.  1908,  Oct.  ;  ^Gaz.  Hebd.  des  Sci. 
Med.  1912,  April  21  ;  ^°Arch.  Internat.  de  Laryngol.  1910,  Sept.  ;  ^^Brit.  Med.  Jour. 
1908,  Oct.  10  ;  ^^Edin.  Med.  Jour.  1910,  April  ;  ^^Trans.  Am.  Laryngol.  Assoc.  1905  ; 
^^Ibid.  ;  ^^Arch.  f.  Laryngol.  Bd.  24  ;  ^^Laryngoscope,  1910  ;  ^Troc.  Roy.  Soc.  Med  . 
1914,  May  ;  ^^Deut.  Zeit.  f.  Chir,  Bd.  116  ;  ^^Calif.  State  Med.  Jour.  1912,  Feb  ;  ^Zeit. 
f.  Ohren.  Bd.  61  ;  ^^Proc.  Roy.  Soc.  Med.  iqii,  May  ;  ^^Rev.  Hebd.  de  Laryngol.  1910,  i  ; 
^'■'V erhandl.  Deutsch.  Natur.  u.  Artze,  1908  ;   ^^Trans.  Med.  Soc.  Lond.  1906,  xxix,  14. 

A.  J.  Wright. 

NEPHRITIS, 

Acute  Nephritis  is  always  a  serious  disease  which  demands  a  guarded  prognosis  ; 
yet  there  is  a  natural  tendency  to  recovery,  and  in  many  cases  recovery  does  take 
place,  with  apparent  return  to  normal  kidney  function.  Some  authorities  hold, 
however,  that  complete  recovery  is  more  apparent  than  real,  and  that  a  kidney, 
once  attacked  with  acute  inflammation,  is  left  permanently  weak  and  Hable  to 
recurrence  of  inflammatory  disease  :  this  is  particularly  well  illustrated  in  the 
case  of  scarlatinal  nephritis.  In  considering  prognosis  in  a  given  case,  the  first 
essential  is  to  establish  the  diagnosis  of  acute  nephritis,  and  to  eliminate  the 
existence  of  an  acute  exacerbation  in  the  course  of  a  subacute  or  chronic 
nephritis.  Diagnosis  may  be  easy  in  private  practice,  if  the  physician  is  familiar 
with  the  patient  before  the  onset  of  his  illness ;  but,  when  seen  for  the  first  time 
during  the  attack,  diagnosis  may  present  difficulties.  An  acute  onset,  with 
possibly  some  fever  ;  a  urine  small  in  amount,  of  high  specific  gro-vity,  containing 
copious  albumin,  blood,  and  numerous  tube-casts  ;  an  absence  of  definite  cardio- 
vascular changes  :  these  point  to  an  acute  nephritis.  If  cardiovascular  changes 
are  recognizable,  the  physician  is  bound  to  suspect  the  existence  of  an  acute 
exacerbation  in  the  course  of  a  chronic  nephritis.  An  estimation  of  the  quantity 
and  specific  gravity  of  the  twenty-four  hours  urine  will,  at  times,  give  assistance. 
If  the  amount  be  about  the  normal,  and  the  specific  gravity  a  little  low,  an  under- 
lying chronic  condition  should  be  suspected,  and  a  guarded  prognosis  given. 
Unfortunately  for  diagnosis,  acute  nephritis  does  not  always  show  the  frank 
onset  as  given  in  the  text-books,  but  may  begin  insidiously,  and  be  only  discovered 
when  its  existence  for  some  time  has  led  to  feelings  of  ill-health,  and  on  examin- 
ation of  the  urine  the  presence  of  albumin  and  blood  is  discovered.  In  such 
cases,  the  diagnosis  is  often  difficult,  and  the  ultimate  prognosis  does  not  seem 
to  be  so  favourable  as  when  the  onset  is  sudden  and  frank.  The  patient's  history 
may  aid  by  putting  the  physician  on  his  guard  ;  previous  headache,  polyuria, 
frequency  of  micturition  at  night,  point  to  a  chronic  lesion.  In  health,  as  is  well 
recognized,  the  amount  of  urine  secreted  during  the  twelve  hours  of  day  is  three 
to  four  times  the  amount  of  that  secreted  during  the  twelve  hours  of  night.     In 


NEPHRITIS  363 

certain  diseased  conditions,  and  especially  in  chronic  nephritis,  this  ratio  is 
altered,  and  the  quantity  of  night  urine  may  equal,  or  even  exceed,  the  quantity 
secreted  during  the  day.  This  leads  to  a  complaint  of  frequency  of  micturition 
at  night,  a  complaint  which  may  be  one  of  the  first  symptoms  for  which  advice 
is  sought  in  chronic  interstitial  nephritis. 

If  the  diagnosis  of  acute  nephritis  be  established,  what  are  the  patient's 
chances  of  complete  recovery,  and  what  of  the  duration  of  the  disease  ?  The 
statistics  of  the  Royal  Infirmary,  Edinburgh,  show  that,  during  the  years  1904 
to  19x2,  400  cases  of  nephritis,  diagnosed  as  acute,  came  under  treatment.  Of 
these,  1 85  were  discharged  as  cured,  giving  a  percentage  of  cure  as  46  ;  while  140 
were  discharged  as  '  relieved,'  i.e.,  had  passed  into  a  subacute  or  chronic  condi- 
tion, with  relief  of  symptoms,  but  liable  at  any  time  to  a  relapse,  with  an  acute 
exacerbation  of  their  chronic  disease.  The  mortality  in  the  400  cases  was  51, 
or  12  per  cent.  Such  statistics,  though  they  cannot  be  strictly  applicable  to 
nephritis  in  private  practice,  are,  tnevertheless,  far  from  reassuring,  and  show 
how  guarded  the  prognosis  must  be.  In  giving  a  prognosis,  the  practitioner  is 
guided  by  the  severity  of  the  attack  and  the  cause  of  the  affection.  Thus,  the 
acute  nephritis  of  scarlet  fever,  and  the  true  acute  nephritis  of  diphtheria,  may 
be,  and  often  are,  very  rapidly  fatal.  On  the  other  hand,  in  a  considerable 
number  of  cases  of  nephritis  not  consequent  upon  a  specific  infection,  the  acute 
symptoms  subside,  the  albuminuria  may  disappear,  and  the  patient  may  be 
discharged  as  cured  after  an  average  stay  in  hospital  of  six  weeks.  Even  then 
prognosis  must  be  guarded  ;  for  subsequent  attacks  are  common,  and  the 
inflammatory  affection  does  not  clear  up  with  the  same  facility  on  the  second 
occasion.  The  principal  factors  which  influence  prognosis  during  the  acute  stage 
are  :  the  amount  of  urine  which  the  kidneys  are  capable  of  secreting  ;  the 
condition  of  the  cardiovascular  system  ;  the  presence  or  absence  of  uraemic 
symptoms  and  secondary  inflammatory  conditions. 

When  the  quantity  of  urine  is  reduced  to  a  few  ounces  of  a  highly  albuminous, 
blood-stained  fluid,  or  when  there  is  complete  anuria,  prognosis  is  very  grave. 
Complete  anuria  is  said  by  some  to  be  necessarily  fatal  ;  but,  while  this  is 
commonly  true,  it  is  not  universally  so,  as  cases  are  recorded,  and  it  is  the  writer's 
experience,  that  recovery  may  take  place  after  from  twelve  to  fourteen  hours, 
or  even  more,  of  complete  suppression. 

The  condition  of  the  cardiovascular  system  merits  careful  consideration.  A 
frequent,  irregular  pulse,  with  evidence  of  loss  of  myocardial  tonicity,  is  always 
of  grave  import.  The  gravity  of  the  condition  will  be  accentuated  if  haematuria, 
or  possibly  haemorrhage  from  the  alimentary  canal,  has  led  to  any  considerable 
anaemia  ;  in  fact  the  presence  of  marked  anaemia  may  turn  the  scale  against 
recovery.  Pericarditis  is  usually  a  terminal  phenomenon,  and  is  commonly  of 
streptococcal  origin. 

Urcsmia  is  a  common  cause  of  death,  especially,  according  to  Dickenson,  in 
patients  over  sixteen  years  of  age  ;  in  younger  patients,  inflammations  of  the 
respiratory  tract  are  even  more  fatal  than  uraemia.  CEdema  of  the  lungs  and 
of  the  glottis  are  very  grave  phenomena,  which  may  appear  with  great  sudden- 
ness, and  prove  fatal  in  a  few  hours. 

The  question  of  prognosis  in  acute  nephritis  is  always  difficult  and  uncertain. 
Most  surprising  recoveries  may  take  place.  Equally  surprising  and  disappointing 
fatalities  may  occur,  say,  from  a  uraemic  convulsion  in  a  patient  who,  casually 
examined,  does  not  appear  to  be  in  a  critical  condition.  As  with  treatment,  so 
with  prognosis  ;  every  case  must  be  carefully  studied,  considered  on  its  own 
merits,  and  due  weight  given  to  the  more  important  factors.  Amongst  other 
factors,  consideration  must  be  given  to  response  to  treatment.     Favourable  signs 


364  INDEX     OF     PROGNOSIS 


in  the  early  stages  are  an  increase  in  the  quantity  of  urine  and  a  diminution  in  the 
oedema;  in  the  later  periods,  diminution  in  the  albumin,  blood,  and  formed 
elements  in  the  urine,  and  a  definite  diuresis.  When  improvement  is  taking 
place,  not  only  is  there  an  increase  in  the  quantity  of  urine  and  a  diminution  in 
the  amount  of  albumin,  but  a  change  takes  place  in  the  character  of  the  deposit : 
epithelial  cells  and  free  blood-corpuscles  become  less  numerous,  and  epithelial 
and  blood-casts  are  gradually  replaced  by  the  hyaline  and  granular  varieties.  It 
has  been  suggested  that  some  prognostic  value  can  be  attached  to  the  size,  and 
especially  to  the  breadth,  of  the  tube-casts  found  in  the  deposit — large  broad 
epithelial  casts  showing  a  profound  desquamation  of  the  tubules, — but  it  seems 
very  doubtful  if  reliance  can  be  placed  on  this  factor.  At  times,  in  the  course 
of  an  acute  nephritis,  improvement  seems  to  take  place — albumin  diminishes, 
the  urinary  quantity  returns  to  about  the  normal — but  the  patient  remains 
somewhat  anaemic,  a  little  oedema  may  be  found  about  the  eyes  and  ankles,  the 
centrifuge  shows  the  presence  of  granular  and  fatty  casts,  and,  after  a  time,  the 
radial  artery  becomes  faintly  palpable.  Such  a  patient  is  passing  into  a  condition 
of  subacute  diffused  nephritis,  and  ultimate  recovery  seems  doubtful.  Particu- 
larly disappointing  are  cases  where  improvement  is,  at  first,  apparently  rapid, 
the  urinary  amount  returns  to  the  normal,  with  only  a  trace  of  albumin,  and 
casts  are  difficult  to  find,  even  with  the  centrifuge :  yet,  whenever  the  diet  is 
altered  from  the  minimum  of  protein  and  the  maximum  of  carbohydrate  and 
fat,  a  fresh  exacerbation  takes  place,  accompanied  by  haematuria.  In  such 
cases,  the  kidneys  have  been  so  damaged  that  they  cannot  undertake  a  reasonable 
amount  of  work,  and  the  chance  of  ultimate  recovery  is  not  good.  Yet,  in  acute 
nephritis,  even  when  apparently  of  a  hopeless  character,  there  is  always  a  chance 
of  recovery,  which  encourages  the  physician  to  persevere  in  therapeutic  measures. 
The  writer  well  remembers  the  case  of  a  young  man  who  had  been  ill  for  two 
months.  The  urine  was  greatly  reduced  in  quantity,  and  contained  copious 
albumin,  blood,  and  tube-casts  of  all  varieties.  There  was  universal  anasarca, 
so  marked  as  to  require  draining  :  Southey's  tubes  were  introduced  into  the  legs, 
and  a  trocar  into  the  abdomen.  For  five  days  the  patient  lived  on  a  nitrogen- 
and  chloride-poor  diet,  and  passed  most  of  his  time  seated  on  the  edge  of  his  bed 
with  the  feet  dependent,  draining  continuously,  the  tubes  being  changed  from 
time  to  time.  With  the  disappearance  of  the  oedema  there  was  rehef  of  the 
circulation,  the  rested  kidneys  regained  their  functional  activity,  and  within 
a  few  months  the  patient  passed  an  Army  Board  for  a  commission  in  India. 

One  may  sum  up  experience,  then,  by  saying  that,  in  acute  nephritis,  prognosis 
must  always  be  guarded  ;  recovery  may  take  place,  even  in  apparently  hopeless 
cases  ;  but  a  considerable  proportion  of  the  suffers  pass  into  a  subacute  or 
chronic  condition,  with  interstitial  and  cardiovascular  changes,  from  which 
complete  recovery  never  takes  place.     {See  also  Scarlet  Fever.) 

Chronic  Diffused  Nephritis  is  very  justly  looked  upon  as  a  grave  condition, 
the  prognosis  in  which  is  bad.  Cases  are  recorded  where  recovery  has  taken 
place  ;  but  there  always  remains  the  doubt  if  the  line  had  been  sufficiently  drawn 
between  a  somewhat  persistent  form  of  acute  nephritis  and  a  true  chronic  diffused 
nephritis.  The  fatal  issue  may  occur  in  from  six  months  to  two  years,  and  may 
result  from  general  exhaustion,  with  pronounced  anaemia.  These  patients 
frequently  exhibit  profound  alimentary  disturbance,  and  can  neither  take 
nor  assimilate  sufficient  nourishment.  Frequently  there  is  failure  of  the 
myocardial  tonicity,  with  dilatation  and  pronounced  anasarca.  Uraemia,  in  its 
protean  manifestations,  or  pneumonia,  may  prove  the  terminal  feature  ;  or  an 
infective  process,  resulting  in  an  inflammation  of  a  serous  membrane. 

Prognosis  will  always  be  grave,  but  certain  features  will  help  in  assessing  the 


NEPHRITIS  365 

gravity.  When  there  is  marked  diminution  in  the  quantity  of  urine,  and 
anasarca  is  universal  and  extreme,  and  the  phenol-sulphone-phthalein  and  other 
tests  show  a  marked  loss  of  functional  activity,  the  patient  will  seldom  survive 
more  than  a  few  months.  When  the  urinary  quantity  is  not  much  reduced 
below  the  normal,  and  the  urine,  though  containing  a  large  amount  of  albumin, 
shows  only  a  limited  number  of  tube-casts  and  leucocytes,  and  the  functional 
activity  is  not  pronouncedly  reduced,  the  condition  may  run  a  much  more  chronic 
course,  and  pass  ultimately  into  the  '  small  white  kidney.'  The  patient  may 
have  periods  of  fair  health  ;  but  a  small  upset,  such  as  a  mild  tonsillitis,  may 
precipitate  grave  symptoms,  with  a  recurrence  of  oedema ;  and  during  one  of 
these  exacerbations  the  patient  dies.  Help  in  prognosis  may  be  obtained  by 
considering  the  functional  activity  of  the  kidneys,  the  condition  of  the  circulatory 
system,  and  the  results  of  treatment.  When  there  is  marked  delay  in  the 
excretion  of  iodide  of  potash,  or  of  phenol-sulphone-phthalein,  the  prognosis  is 
grave.  Yet  at  times  the  excretion  of  the  phthalein  may  be  as  low  as  16  per  cent 
in  two  hours,  months  before  the  fatal  issue.  Cardiac  dilatation  and  arterial 
degeneration  are  of  grave  import.  CEdema  may  be  due  to  salt  retention  ;  but 
salt  retention  may  be  combined  with  degenerative  changes  in  the  smaller  vessels, 
and  with  cardiac  failure.  When  oedema  is  due  to  salt  retention,  there  will  be 
diminished  chloride  excretion  in  the  urine,  and  a  salt-free  diet  will  usually  give 
considerable  amelioration  of  symptoms.  When  salt-free  diet  is  instrumental 
in  producing  a  diuresis  with  diminished  oedema,  prognosis  is  less  grave  than 
when  vascular  degeneration  and  cardiac  failure  are  causal  factors  which  are 
uninfluenced  by  a  salt-free  diet.  In  those  cases,  the  mere  mechanical  presence 
of  the  fluid  in  the  cavities  and  tissues  has  a  deleterious  influence  on  the  functional 
activity  of  the  organs,  and  increases  malnutrition.  Neither  the  alimentary 
canal  nor  the  heart  can  carry  on  its  work  efficiently ;  anaemia  and  malnutrition 
increase  ;  and  defective  coronary  circulation  adds  to  the  difficulties  of  the  already 
embarrassed  heart.  Again,  it  may  be  found  that,  at  times,  a  period  of  protein- 
free  diet  will  give  considerable  relief  of  symptoms.  Speaking  generally,  then, 
it  may  be  concluded  that  response  to  treatment  makes  the  immediate  prognosis 
less  serious,  while  want  of  proper  response  renders  it  very  grave. 

Chronic  Interstitial  Nephritis. — Pathologists  are  gradually  returning  to  the 
view  that  the  underlying  and  primary  factor  in  chronic  interstitial  nephritis  is  a 
disease  of  the  smaller  blood-vessels,  a  widely  diffused  disease  of  the  arterioles  of 
the  internal  organs,  in  which  the  vessels  of  the  kidney  participate.  The  disease, 
in  its  fully  developed  form,  involves  the  kidney,  producing  the  primary  contracted 
or  small  red  granular  kidney.  This  being  so,  it  may  at  once  be  granted  that  the 
condition  is  incurable.  True  it  is  that  Senator  has  stated  that  recovery  is 
possible  if  the  disease  is  taken  early  ;  but  this,  if  correct,  is  exceptional,  and  is 
outside  the  field  of  practical  politics.  Yet  cases  as  seen  in  private  practice  must 
not  be  assessed  at  the  same  degree  of  gravity  as  the  fully  developed  picture 
obtaining  in  the  hospital  ward.  The  established  diagnosis  of  chronic  interstitial 
nephritis  does  not  by  any  means  condemn  the  sufferer  to  a  life  of  invalidism.  In 
the  writer's  experience,  the  existence  of  chronic  interstitial  nephritis  has  been 
compatible  with  an  active  business  career  for  fifteen  years  after  the  diagnosis 
was  definitely  established.  Other  observers  have  recorded  cases  where  the 
condition  has  lasted  twenty,  and  even  thirty,  years.  Prognosis  depends,  not 
so  much  on  anatomical  changes,  as  upon  the  functional  activity  of  the  kidney 
and  of  the  heart.  This  being  granted,  it  is  obvious  that  the  patient  has  a  right 
to  a  full  knowledge  of  his  condition  and  the  factors  which  should  regulate  his 
life, — for  much  of  the  outlook  will  depend  upon  his  ability  to  lead  a  simple  life. 
It  is  fortunate  when  tlie  disease  is  discovered  early,  and  when  the  physician  can 


366  INDEX     OF     PROGNOSIS 

obtain  the  hearty  co-operation  of  the  patient  in  regulating  diet  and  working 
hours,  with  a  view  to  maintaining  reasonable  health  and  prolonging  life.  As 
Janewary  points  out,  cases  of  chronic  interstitial  nephritis  fall  into  two  groups. 
In  one  group  the  clinical  picture  is  that  of  some  degree  of  cardiac  insufficiency, 
and  death  is  a  cardiac  death.  In  the  second  the  predominant  symptoms  are 
cerebral — headache,  vertigo,  and  apoplectic  attacks — and  there  is  evidence  of 
severe  renal  insufficiency.  In  forming  an  estimate  of  the  gravity  of  the  prog- 
nosis, consideration  must  be  given  to  the  condition  of  the  circulation,  to  the 
kidney  function,  and  to  the  occurrence  of  complications  of  a  ursemic  type. 
Every  case  will  require  individual  study,  and  too  much  importance  must  not  be 
given  to  a  single  factor. 

Cardiac  hypertrophy  of  the  concentric  type,  with  high  blood-pressure,  will  be 
present ;  yet  if  the  functional  activity  of  the  organ  be  maintained,  immediate 
prognosis  may  be  favourable.  Unfavourable  phenomena  are  those  suggestive 
of  loss  of  compensation — palpitation,  dyspnoea  on  mild  exertion,  and  marked 
increase  in  the  area  of  cardiac  dullness,  with  some  oedema  about  the  ankles. 
These  factors  show  a  loss  of  tonicity.  No  doubt  they  may  disappear  under 
therapeutic  measures,  but  they  show  that  the  heart  has  been  working  beyond 
its  reserve,  and  that  a  breakdown  is  imminent.  In  this  respect,  consideration 
of  the  blood-pressure  is  important.  It  may  be  accepted  that,  within  reasonable 
limits,  high  blood-pressure  is  necessary  in  these  cases  to  maintain  the  functional 
activity  of  the  kidney ;  but  excessive  blood-pressure  throws  extra  work  on  the 
heart,  and  it  may  break  down  under  the  strain.  A  blood-pressure  of  i8o  to 
200  mm.  Hg,  or  over,  must  tax  the  powers  of  the  heart  considerably,  and  must 
lead  in  the  end  either  to  cardiac  insufficiency  or  to  a  cerebral  hcemorrhage.  A 
systematic  estimation  of  the  blood-pressure  will  greatly  help  the  practitioner  in 
forming  a  prognosis.  Given  that  it  is  moderately  high,  constant  from  month 
to  month,  with  no  signs  of  failing  tonicity,  and  with  fair  general  health,  prognosis 
may  be  regarded  as  comparatively  favourable.  If,  however,  notwithstanding 
treatment,  the  blood-pressure  is  persistently  rising,  prognosis  becomes  grave  ; 
either  the  heart  will  fail,  or  a  cerebral  haemorrhage  will  close  the  scene.  [See 
Arterial  Tension,  High.) 

A  factor  which  must  be  taken  into  consideration  in  prognosis  is  the  patient's 
ability  and  willingness  to  carry  out  treatment.  The  patient  who  can  spend  the 
winter  months  in  an  equable  and  mild  climate,  pay  an  annual  visit  to  a  spa,  and 
carefully  carry  out  directions  as  regards  the  avoidance  of  chulls,  over-work,  and 
dietetic  errors,  has  obviously  a  far  better  chance  of  prolonged  life  than  the 
working  man  exposed  to  all  weathers,  or  the  harassed  professional  or  business 
man  living  a  life  of  strain. 

The  manner  of  death  in  chronic  interstitial  nephritis  must  always  be  uncertain  ; 
most  commonly,  however,  it  is  a  cardiac  death,  a  death  from  failing  compensa- 
tion, at  times  combined  with  distressing  ursemic  symptoms.  Sudden  death 
from  cerebral  haemorrhage  is  not  uncommon. 

Albuminuric  Retinitis. — The  practitioner  will  find  the  systematic  use  of  the 
ophthalmoscope  a  most  valuable  aid  to  prognosis  in  chronic  nephritis.  The 
retinal  changes  which  may  be  present  have  been  enumerated  by  Gowers  as  : 
Diffused  opacity  from  oedema,  white  patches,  hjemorrhages,  optic  papilUtis, 
diffused  retinitis,  and  optic  changes  consecutive  to  inflammation.  Of  these 
changes,  the  first  three  are  comparatively  common,  the  second  three  are  of  less 
frequent  occurrence.  The  most  characteristic  and  striking  are  the  white  or 
yellowish  glistening  spots  about  the  macula  and  optic  disc  and,  in  more  advanced 
cases,  scattered  through  the  retina.  At  first  small  and  scattered,  they  may 
coalesce  and  form  larger  spots  which,  situated  in  the  proximity  of  the  disc,  may 


NEPHRITIS  367 

be  as  large  as  the  disc  itself.  At  the  macula,  they  occur  as  numerous  small 
glistening  points  ;  or  they  may  radiate  as  interrupted  lines,  or  fan-like  streaks, 
in  all  directions.  These  changes  are  degenerative  in  character,  and  may  be 
accompanied  by  hasmorrhagic  extravasations ;  or  extravasations  may  occur 
alone,  and  may  vary,  according  to  age,  from  the  bright  red  of  the  recent,  to  the 
dark  red  and  finally  atrophic  patch  marking  the  site  of  absorption  of  a  former 
extravasation.  The  vessels  of  the  retina  will  often  show  sclerosis,  and  as  Gunn 
pointed  out,  they  have  an  exceptionally  bright  reflex  ;  the  central  light  streak 
is  very  distinct  and  sharp,  while  the  whole  surface  of  the  vessel  is  of  a  somewhat 
lighter  shade  than  usual.  These  changes  in  the  retina  are  degenerative  in 
character,  and  are  collectively  described  as  albuminuric  retinitis.  They  occur 
most  frequently  in  chronic  interstitial  nephritis,  and  are  of  very  grave  import. 
A  patient  with  definite  albuminuric  retinitis  seldom  survives  more  than  two 
years  ;  a  few  cases  are  recorded  where  the  patient  has  lived  for  longer,  but 
these  are  the  exception,  not  the  rule.  The  gravity  of  albuminuric  retinitis  in 
its  bearing  on  prognosis  cannot  be  over-estimated.  (Such  a  statement  does  not,  of 
course,  apply  to  the  retinal  changes  which  may  occur  in  the  kidney  of  pregnancy  ; 
there,  complete  recovery  of  kidney  health  may  occur,  but  the  patient  may  be 
left  with  permanently  damaged  vision). 

Estimation  of  Renal  Function. — To  the  physician,  anatomical  changes  are  only 
important  in  so  far  as  they  interfere  with  the  functional  activity  of  an  organ. 
By  investigation  of  the  activity  of  the  kidney,  valuable  data  will  be  obtained 
for  the  estimation  of  prognosis  in  nephritis.  Of  the  different  functional  tests, 
the  most  valuable  is  the  phenol-sulphone-phthalein  test  described  by  Kowntree 
and  Geraghty  ;    the  simplest  for  the  practitioner  is  the  iodide  of  potash  test. 

The  phenol-sulphone-phthalein  test  depends  upon  the  capacity  of  the  kidney 
for  the  excretion  of  the  pigment.  The  apparatus  required  consists  of  a  one-litre 
flask  and  a  colorimeter.  Before  making  the  observation,  the  patient  is  given 
a  drink  of  water.  The  injection,  which  can  be  obtained  in  an  ampoule,  i  c.c.  of 
which  contains  6  mgrams  of  the  phthalein,  is  injected  into  the  muscles  of  the 
lumbar  region.  The  patient  empties  the  bladder  at  the  end  of  one  hour  after 
the  injection,  and  again  at  the  end  of  the  second  hour.  The  urine  voided  at  the 
end  of  one  hour  is  poured  into  a  litre  flask,  and  rendered  strongly  alkaline  with 
caustic  soda  solution  to  give  the  maximum  red  colour ;  water  is  now  added  to 
the  litre  mark,  and  the  mixture  shaken  and,  if  necessary,  filtered  to  remove 
phosphates.  The  standard  colour  for  comparison  is  obtained  by  the  dilution 
of  I  c.c.  of  phthalein  solution  in  a  litre  of  water.  This  is  placed  in  the  standard 
tube  of  the  instrument,  while  the  urinary  mixture  is  placed  in  the  observation 
tube  ;  the  colours  are  adjusted,  the  scale  is  read  off,  and  the  percentage  of  excreted 
pigment  obtained.  Unless  the  excretion  of  phthalein  is  very  much  retarded, 
the  ordinary  urinary  pigment  does  not  interfere  with  accurate  estimation.  In 
health,  43  to  70  per  cent  (usually  about  50  per  cent)  of  the  pigment  is  excreted 
during  the  first  hour,  70  to  90  per  cent  during  the  first  two  hours  ;  excretion  is 
practically  complete  after  two  hours.  A  diseased  kidney  shows  a  very  marked 
decrease  in  excretion  during  the  first  two  hours.  No  pigment  may  appear  by 
the  end  of  the  second  hour  in  very  grave  cases  of  renal  inadequacy.  Excretion 
is  noticeably  decreased  in  acute  nephritis,  but  it  is  especially  in  subacute  and 
chronic  conditions  that  the  test  is  of  value  in  estimating  prognosis.  Phthalein 
is  excreted  mainly,  if  not  entirely,  by  the  tubules,  and  deficient  excretion  points 
to  a  deficient  functional  activity  of  the  tubules.  No  absolute  figures  can  be 
given  as  a  guide  to  prognosis  from  the  functional  test ;  but,  speaking  generally, 
an  excretion  of  50  per  cent  and  under  shows  serious  renal  inadequacy.  In 
many  cases  of  parenchymatous  nephritis,  excretion  falls  to  30  per  cent  or  lower  ; 


368  INDEX     OF     PROGNOSIS 

the  lower  the  percentage,  the  graver  the  prognosis.  In  chronic  interstitial 
nephritis,  when  the  kidney  function  is  being  fairly  well  maintained,  excretion 
will  be  from  50  to  60  per  cent.  When  ursemic  phenomena  are  present,  the 
percentage  will  fall  very  low,  in  some  cases  even  to  zero.  In  these  cases  there  is 
pronounced  inadequacy,  with  nitrogen  retention.  In  chronic  nephritis,  a 
pronouncedly  low  excretion  points  to  an  unfavourable  prognosis,  even  though 
no  apparent  uraemic  phenomena  are  present. 

The  iodide  of  potash  test  is  simple,  but  not  of  the  same  value  as  the  phthalein 
test.  If  ji  gr.  of  iodide  of  potash  be  given  to  a  healthy  individual,  it  will  be 
recognizable  in  the  urine  in  a  very  few  minutes  ;  and  the  total  quantity  will  be 
excreted  within  about  sixty  hours,  when  the  urine  will  no  longer  give  the  tests 
for  iodine.  Iodide  of  potash  is  eliminated  by  the  tubules,  and  when  there  is 
disease  of  the  tubules,  the  elimination  of  iodide  is  greatly  delayed,  the  time  being 
doubled  or  even  trebled  in  some  cases.      {See  also  Uraemia.)         Francis  D.  Boyd. 

NERVE  INJURIES. — These  differ  from  those  of  other  structures  by  reason 
of  their  function.  Not  only  does  the  nerve  itself  suSer,  but  the  parts 
supplied  by  it  are  affected,  and  it  is  with  regard  to  these  as  well  as,  and  more 
often  than,  to  the  nerve  itself,  that  the  treatment  is  directed  and  the  prognosis 
depends. 

Injury  may  affect  a  nerve  in  its  course  (in  continuity)  or  at  its  termination, 
one  of  its  branches  of  distribution  being  involved. 

Injury   in  Continuity. 
Two  groups  are  recognized  : — 

1.  Those  in  which  the  naked-eye  continuity  of  the  nerve  is  interrupted  partially 
or  completely,  which  I  am  accustomed  to  term  anatomical  division. 

2.  Those  in  which  the  injury  produces  partial  or  complete  interruption  of 
conduction  without  naked-eye  solution  of  continuity.  To  this  I  give  the  name 
physiological  division. 

Prognosis  in  General. — -Prognosis  depends  not  only  upon  prompt  treatment 
at  the  time  of  the  accident,  but  to  a  large  extent  on  efficient  supervision  for 
many  months.  The  treatment  of  injury  to  a  nerve  in  its  continuity  consists  in 
keeping  up  the  nutrition  of  the  parts  supplied  by  it  and  preventing  the  occur- 
rence of  contractures  in  muscles  opposed  to  those  affected,  until  conduction 
is  restored  by  natural  means  alone  or  aided  by  operation.  In  comparatively 
few  cases,  apart  from  accidental  wounds  in  which  it  is  essential,  is  operation 
necessary  ;  it  should  always  be  avoided  if  possible,  and  sufficient  time  given 
to  be  certain  that  recovery  will  not  ensue  unaided. 

Relaxation  of  paralyzed  muscles  must  be  maintained  until  voluntary  power 
is  restored  ;  unless  this  is  done,  recovery  may  be  indefinitely  delayed.  This 
muscular  relaxation  is  the  most  important  point  in  treatment,  but  it  is  the  one 
most  often  neglected.  It  is  quite  useless  to  undertake  the  treatment  of  a  case 
of  nerve  injury  unless  this  can  be  carried  out. 

In  cases  needing  operation  it  is  too  often  assumed  that  when  once  the  ends 
of  the  nerve  have  been  united  the  surgeon's  work  has  ceased  ;  it  has  only  just 
begun.  The  careful  supervision  of  the  patient  and  the  direction  of  the  treat- 
ment, it  may  be  for  two  or  three  years,  is  most  important. 

Complete  Anatomical  Division. 
In  complete  anatomical  division,   immediate  primary  suture  is  the  correct 
procedure,  the  nerve  being  united  by  absorbable  suture  and  wrapped  to  prevent 
the  formation  of  adhesions. 


NERVE     INJURIES  369 


Prognosis  after  Primary  Suture. — Primary  union,  by  which  was  understood 
union  of  the  divided  ends  of  a  nerve  without  the  occurrence  of  complete  degener- 
ation in  its  peripheral  end,  is  not  possible.  This  subject  excited  considerable 
controversy  between  the  years  1 860-1 880.  To  Letievant^  is  due  the  principal 
credit  of  explaining  by  his  clinical  observations  the  fallacies  upon  which  the 
assumption  was  based. 

Before  recovery  can  take  place,  degeneration  must  occur  in  the  peripheral 
end  of  the  nerve,  followed  by  regeneration  and  reunion  with  the  central  nervous 
system. 

Many  papers  have  been  written  concerning  the  time  of  recovery  after  primary 
suture,  but  in  the  majority  of  instances  they  consist  of  collections  of  isolated 
cases  recorded  by  others.  The  fallacies  are  so  numerous,  the  question  of  the 
exact  details  of  the  operation  and  after-treatment  is  so  impossible  to  define  in 
collections  of  this  type,  that  the  conclusions  are  of  little  value. 

One  of  the  earliest  tables  of  collected  cases  occurs  in  Howell  and  Ruber's'-^ 
masterly  paper  on  the  regeneration  of  nerves.  They  concluded  that  66  to 
80  per  cent  of  the  cases  recovered. 

Sir  Anthony  Bowlby^  appears  to  have  been  the  first  to  attempt  to  settle 
the  question  by  personal  observation  of  a  series  of  cases.  He  observed  the 
results  of  28  cases  of  primary  suture,  in  many  of  which,  however,  the  first  note 
was  made  several  years  after  suture.  He  considered  16  were  successful  and 
4  failures. 

Dr.  Henry  Head  and  the  writer*  published  a  series  of  cases  investigated  at 
short  periods  from  suture  to  recovery.  The  question  was  fully  considered 
by  the  latter  in  his  Erasmus  Wilson  Lectures  in  the  following  year." 

Perfect  recovery  is  possible  after  primary  suture  ;  perfect  function  may  be 
restored  to  the  affected  muscles,  and  no  difference  noticed  by  the  patient  in 
the  sensation  of  the  part  as  compared  with  the  corresponding  sound  one. 
Although  possible— and  I  have  seen  it  follow  primary  suture  even  of  the  ulnar 
nerve — it  is  unusual.  For  it  to  occur,  the  operation  of  suture  must  have  been 
carried  out  with  great  care,  the  wound  must  heal  by  first  intention,  and  the 
after-treatment  be  efficient. 

The  prognosis  will  depend  to  a  certain  extent  upon  the  nerve  injured  ;  for 
example,  the  musculospiral  nerve  in  the  lower  third  of  the  arm  carries  no 
exclusive  supply  to  any  portion  of  skin,  and  the  muscles  it  innervates  are  not 
so  intimately  associated  with  delicate  movements  of  the  fingers  as  are  those 
supplied  by  the  ulnar.  Complete  recovery  is  reached  more  frequently  and  more 
rapidly  than  in  other  nerves. 

The  further  the  seat  of  injury  from  the  periphery,  the  longer  the  time  neces- 
sary to  full  recovery,  and  the  less  likely  is  it  to  occur. 

I  have  personally  observed  over  60  cases  of  primary  suture.  In  all,  motor 
power  was  regained  and  the  second  stage  of  sensory  recovery  completed.  It 
is  unusual,  however,  for  complete  recovery  to  ensue.  In  a  recent  paper, 
Spisharny^  states,  from  investigation  of  18  cases  of  suture,  that  perfect  recovery 
did  not  occur  in  a  single  case,  but  66  per  cent  of  the  patients  were  able  to  resume 
work. 

If  the  nerve  injured  is  the  median  or  ulnar,  it  is  improbable  that  recovery, 
either  motor  or  sensory,  will  be  sufficient  to  enable  delicate  movements  to  be 
skilfully  performed.  Thus,  wliile  the  hand  might  be  perfectly  useful  to  an 
unskilled  labourer,  it  would  be  a  useless  member  to  an  artist  or  executive 
musician. 

The  time  after  suture  at  which  recovery  occurs  varies  with  the  distance  of 
the  point  of  suture  from  the  periphery  and  the  method  of  healing  of  the  wound  ; 

24 


370  INDEX     OF     PROGNOSIS 

suppuration  prolongs  it  very  considerably.  In  division  of  one  of  the  nerves 
of  the  forearm,  muscular  recovery  commences  about  nine  months  after  suture, 
but  perfect  sensory  recovery  cannot  be  expected  under  three  years. 

Secondary  Suture. — Recovery  is  much  slower  and  prognosis  less  hopeful 
than  after  primary  suture.  In  none  of  my  37  personal  cases,  or  in  many  others 
which  have  been  seen  at  varying  times  after  suture,  did  perfect  recovery  ensue. 
While  this  is  possible  after  primary  suture,  it  is  improbable  after  secondary. 

The  first  question  to  be  considered  is  the  relation  of  the  interval  between 
division  and  suture  to  recovery.  Howell  and  Huber,'  and  Kennedy,*  among 
others,  considered  that  the  prognosis  was  better  and  the  time  of  recovery  shorter, 
the  sooner  after  injury  the  nerve  was  sutured.  I  stated  in  my  Erasmus  Wilson 
Lectures  that  there  was  no  direct  relation  between  the  length  of  time  which 
has  elapsed  since  the  injury  in  cases  in  which  operation  was  performed  before 
the  lapse  of  two  to  three  years.  This  is  in  agreement  with  Bowlby's^  experience. 
Although  I  believe  that  the  time  after  injury  at  which  suture  is  performed  has 
no  direct  relationship  to  the  length  of  time  necessary  for  recovery,  it  has  an 
important  indirect  one,  in  that  most  of  the  factors  hindering  complete  recovery 
develop  as  time  advances. 

Although  instances  of  '  successful  '  operation  have  been  recorded  nine 
(Jessop^**)  and  fourteen  (Chaput^^)  years  after  division,  muscular  recovery  is 
unlikely  after  about  three  years. 

There  are  many  factors  to  take  into  consideration  in  estimating  the  chances 
of  recovery  :  If  the  nerve  was  divided  in  an  open  wound,  its  method  of  healing  ; 
nothing  hinders  recovery  to  so  great  an  extent  as  suppuration :  the  condition 
of  the  muscles  as  regards  wasting  and  the  retention  of  irritability  to  the  constant 
current ;  the  presence  of  contractures  in  opposing  muscles,  and  the  condition 
of  ligamentous  structure  surrounding  joints.  The  condition  of  the  hand  of 
a  patient,  for  example,  who  has  suffered  division  of  the  ulnar  nerve  below  its 
dorsal  branch,  in  whom  a  marked  claw-hand  has  developed,  is  little  likely  to 
be  improved  by  suture,  although  the  muscles  may  regain  their  irritability  to 
the  interrupted  current. 

It  is  extremely  important  to  attempt  to  estimate  the  probable  extent  of 
recovery.  From  the  motor  standpoint,  if  great  wasting  with  contracture  has 
occurred,  as  is  so  common  after  ulnar  injuries,  operation  is  not  worth  under- 
taking ;  if  there  is  no  contraction  on  stimulation  with  the  constant  current  on 
several  examinations,  suture  is  useless.  The  length  of  time  irritability  persists 
varies,  but  I  have  obtained  response  twenty  years  after  division.  But  if 
trophic  ulceration  is  present,  operation  will  cure  it  and  prevent  recurrence,  for 
protopathic  recovery  is  almost  certain,  and  ulceration,  as  Head  and  the  writer 
have  shown,  ceases  on  the  restoration  of  protopathic  sensibility. 

Considerable  interest  attaches  to  the  commencement  of  the  first  stage  of 
restoration  of  sensibility.  From  time  to  time  instances  of  '  rapid  '  return  of 
sensibility  after  secondary  suture  have  been  recorded  by  many  observers,  among 
the  more  recent  being  Ballance^^  ^nd  Kennedy."  I  have  carefully  examined 
for  it  after  operation  in  37  personal  cases,  but  have  not  yet  observed  it.  My 
attention  has  more  than  once  been  drawn  by  hospital  residents  to  the  '  rapid 
return  of  sensibility  to  prick,'  after  secondary  suture,  which,  on  careful  testing 
in  the  usual  manner,  proved  to  be  deep  sensibility.  In  one  patient  upon  whonr 
I  had  performed  secondary  suture  of  the  median  nerve,  it  was  said  that  sensi- 
bility to  prick  had  returned  on  the  day  following  operation.  On  testing,  I 
found  that  he  complained  of  pain  on  pressure,  but  could  not  distinguish  the 
sharpness  of  the  point  of  a  pin  ;  it  was  equally  painful,  and  produced  the  same 
sensation,  as  pressure  with  the  blunt  end  of  a  pencil  ;   moreover,  he  was  entirely 


NERVE     INJURIES  371 


insensitive  to  the  painful  interrupted  current,  and  all  temperature  appreciation 
was  absent.  There  was  no  doubt  that  the  pain  was  that  caused  by  deep  pressure, 
which  could  be  readily  evoked  before  operation. 

The  time  of  commencement  of  the  first  stage  of  sensory  recovery  may  be 
shorter  than  after  primary  suture,  the  changes  of  the  peripheral  end  necessary 
to  regeneration  of  the  nerve  being  advanced  at  the  time  of  suture.  I  have  seen 
it  as  early  as  the  thirtieth  day,  but  much  variability  obtains,  and,  speaking 
generally,  the  time  necessary  for  the  completion  of  the  first  stage  is  always  long, 
and  the  interval  between  the  second  and  third  nearly  double  as  long.  I  have 
never  yet  seen  perfect  sensory  recovery  after  secondary  suture,  although  I 
have  watched  patients  for  over  seven  years,  and  examined  them  up  to  fifteen 
years  after  suture.  In  all,  some  difference  could  be  appreciated  between  the 
two  limbs,  an  area  of  changed  sensibility  remaining,  with  imperfect  appreciation 
of  the  compass  test.  Much  less  variation  occurs  with  regard  to  motor  recovery, 
but  the  time  required  is  invariably  longer. 

Prognosis  after  Nerve  Bridging.  —  Under  the  term  '  nerve  bridging '  are 
included  all  those  procedures  undertaken  to  restore  anatomical  continuity 
when  the  ends  of  a  divided  nerve  cannot  be  brought  into  apposition.  We  have 
a  choice  of  methods  that  have  been  used  more  or  less  successfully  from  time 
to  time.     Those  of  proved  value  may  be  put  into  four  groups. 

1.  Transference  of  a  portion  of  nerve  from  another  source  (nerve  transplant- 
ation) . 

2.  Provision  of  a  path  along  which  the  nerve  may  regenerate  (tubular  suture, 
flap  operations,  etc.). 

3.  Utilization  of  neighbouring  nerve  (anastomosis  or  crossing). 

4.  Shortening  the  limb  by  resection  of  bone. 

Nerve  transplantation  is  the  operation  of  choice.  In  1906'*  I  investigated 
the  recorded  cases  of  nerve  transplantation,  added  fresh  cases,  and  brought 
others  up  to  date.  Among  the  30  cases,  8  were  examples  of  transplantation 
of  human  nerve  (homo-transplantation)  ;  of  these  only  3  were  reported  at  a 
sufficient  interval  after  operation  to  admit  of  recovery.  This  was  complete  in  2. 
Out  of  22  instances  of  transplantation  of  nerve  taken  from  one  of  the  lower 
animals  (hetero-transplantation),  16  were  reported  at  a  period  after  operation 
that  would  have  admitted  of  some  recovery  ;  of  these  only  i,  or  at  the  most  2, 
recovered  completely. 

Tubular  suture  aims  at  providing  a  path  for  the  new  axis-cylinders,  free 
from  fibrous  tissue.  Many  substances  have  been  used  for  this  purpose,  among 
them  decalcified  bone,  collodion,  preserved  animal's  artery.  I  prefer  a  tube 
composed  of  a  portion  of  one  of  the  patient's  superficial  veins.  In  performing 
this  operation  the  nerve  is  prepared  and  both  ends  freshened ;  a  portion  of 
superficial  vein  of  appropriate  size  is  then  excised  and  slipped  over  one  end  of 
the  nerve.  The  ends  are  loosely  united  with  catgut,  the  vein  is  drawn  over  the 
junction,  and  the  whole  surrounded  with  Cargile  membrane.  The  results  given 
by  this  operation  are  superior  to  those  obtained  from  hetero-transplantation. 

The  results  of  flap  operations  have  been  uniformly  unfavourable. 

The  possibility  of  utilizing  neighbouring  nerves  attracted  the  attention  of 
investigators  at  an  early  date.  Two  distinct  operations  are  included — nerve 
crossing  and  nerve  anastomosis.  In  nerve  anastomosis,  an  attempt  is  made  to 
bring  the  axis-cylinders  of  the  affected  nerve  into  end-to-end  contact  with  some 
of  those  of  the  sound  nerve  ;  in  nerve  crossing,  the  peripheral  end  of  the  affected 
nerve  is  united  end-to-end  with  the  central  portion  of  a  divided  sound  nerve. 

Excluding  the  cases  in  which  the  operation  was  performed  on  the  facial  nerve, 
I  collected  25  examples;    of  these   12  were  reported  at  a  suflicicnt  time  after 


372  INDEX     OF     PROGNOSIS 

operation  to  enable  an  opinion  to  be  given  as  to  the  result.  Two  were  un- 
doubtedly perfectly  successful.  Four  were  certainly  improved  by  the  operation, 
and  were  probably  successes,  but  the  records  are  too  scanty  to  enable  a  definite 
opinion  to  be  given.  Thus,  out  of  the  12  cases  reported  sufficiently  long  after 
the  operation,  only  2  were  failures  ;  some  improvement  took  place  in  all  the 
others.  This  is  a  better  result  than  that  given  by  Powers,  ^^  who  considered 
that  50  per  cent  were  successful. 

The  prognosis  in  cases  of  bone-shortening  is  that  of  secondary  suture. 

Incomplete  Anatomical  Division. 

In  order  to  understand  the  prognosis  of  these  injuries,  their  nature  must  first 
be  considered. 

In  wounds  of  nerves  which  do  not  completely  destroy  their  continuity,  it  is 
found  that  at  least  a  third  of  their  diameter  may  be  destroyed  without  producing 
any  change,  or  one  of  a  transient  nature  only,  unless  the  injury  is  near  the 
point  at  which  a  branch  is  given  off,  when  the  symptoms  resemble  those  of 
division  of  that  branch. 

This  is  confirmed  by  the  experiments  of  Bruandet  and  Humbert,^®  who  found 
that  the  fibres  in  a  peripheral  nerve  which  go  to  make  up  any  branch  do  not 
become  grouped  until  just  before  it  leaves  the  parent  trunk.  In  certain  situa- 
tions also — for  example,  in  the  anterior  primary  division  of  the  fifth  cervical 
nerve — the  nerve  fibres  are  arranged  in  a  well-defined  order,  and  incomplete 
division  of  this  nerve  may  entail  complete  division  of  those  motor  fibres  which 
supply  the  spinati  and  deltoid  muscles.  Again,  in  the  trunk  of  the  great  sciatic 
nerve  the  external  and  internal  popliteal  nerves  remain  separate ;  hence 
incomplete  division  of  the  great  sciatic  may  cause  complete  division  of  the 
external  or  internal  popliteal  nerve. 

In  accidental  wounds  of  nerves,  in  addition  to  the  incomplete  anatomical 
division,  there  is  usually  physiological  division,  the  result  of  the  transient 
compression  of  the  intact  nerve  fibres  by  the  cutting  instrument  or  effused 
blood. 

Absence  of  symptoms  in  many  cases  is  due  to  the  fact  that  more  nerve  fibres 
are  present  in  the  trunk  of  a  nerve  than  are  necessary  to  the  supply  of  the  part. 
When  symptoms  are  present,  the  recovery  of  function  is  due  to  restoration 
of  conduction  in  the  fibres  which  have  suffered  an  incomplete  physiological 
division.  Those  fibres  which  are  separated  from  their  nerve  centres  must  of 
course  degenerate  and  regenerate  before  they  can  again  carry  on  their  functions. 
It  must,  however,  be  remembered  that  the  injury  to  the  anatomically  intact 
nerve  fibres  may  be  so  great  that  complete  physiological  division  is  produced  ; 
,  this  may  also  arise  at  a  later  period  as  the  result  of  compression  by  fibrous  tissue. 

If  efficient  treatment  at  the  time  of  the  accident,  or  later,  is  carried  out, 
recovery  is  usually  perfect,  both  motor  and  sensory.  In  some  cases,  however, 
in  which  the  treatment  at  the  time  of  the  injury  was  not  operative,  complica- 
tions ensue.  After  a  period  of  improvement,  deterioration  of  function  sets  in. 
due  to  involvement  in  fibrous  tissue.  Recovery  in  these  cases  does  not  usually 
occur  apai't  from  operation. 

In  other  instances,  pain  arises  in  the  full  distiibution  of  the  injured  nerves, 
sometimes  accompanied  by  hyperalgesia,  in  rare  instances  by  glossy  skin.  In 
these  cases  the  damaged  portion  of  the  nerve  must  be  removed  and  continuity 
re-established  ;    the  prognosis  is  then  that  of  secondary  suture. 

Subcutaneous  Injuries. — Taken  generally,  prognosis  is  much  more  favourable 
than  after  nerve  section,  except  in  the  case  of  traction  injuries  of  the  brachial 
plexus. 


NERVE    INJURIES  373 

As  the  result  of  pressure — long-continued  or  sudden— all  the  immediate 
symptoms  of  complete  division  may  develop.  When  the  injury  is  incomplete 
and  physiological,  recovery  rapidly  ensues.  All  forms  of  sensibility  recover 
together,  and  localization,  so  seldom  restored  after  suture,  is  rapidly  regained. 
With  regard  to  motor  symptoms,  unless  the  reaction  of  degeneration  develop, 
]50wer  is  quickly  regained  by  the  affected  muscles.  Restoration  of  sensibility 
to  all  forms  of  stimulation  is  perfect  usually  within  six  to  twelve  months. 

At  the  end  of  a  fortnight,  if  the  affected  muscles  are  still  paralyzed,  their 
electrical  reactions  should  be  taken.  If  at  this  date  the  muscles  react  to  the 
interrupted  current,  or  give  the  reactions  of  incomplete  division,  non-operative 
treatment  should  be  continued.  Recovery  can  be  confidently  expected  in  the 
former  case  in  a  few  weeks,  in  the  latter  in  a  few  months.  If  true  reaction  of 
degeneration  develop,  the  prognosis  is  unfavourable  ;  operation  becomes 
necessary,  with  all  the  drawbacks  of  secondary  suture.  After  neurolysis  has 
been  carried  out,  recovery  is  usually  rapid. 

Injury  to  Terminal  Branches. 

The  principal  symptom  of  the  involvement  of  the  terminal  branches  of  a 
nerve  in  scar  tissue  or  callus,  is  pain  referred  to  the  distribution  of  the  roots 
from  which  the  affected  nerve  arises,  with  in  some  cases  paresis  or  paralysis. 
These  symptoms  are  seen  most  often  after  finger  amputations. 

The  prognosis  is  good  if  the  condition  causing  the  symptom  is  removed  by 
operation,  when  the  pain  and  tenderness  are  still  confined  to  the  scar  or  stump  ; 
when  they  have  spread  to  other  nerves,  or  are  associated  with  hysteria  or 
muscular  affections,  it  is  by  no  means  favourable. 

If  the  pain  is  not  relieved,  or  recurs,  no  further  local  operation  should  be  done 
if  the  first  was  thorough.  Before  proceeding  to  the  only  remaining  operative 
treatment  in  these  cases — division  of  posterior  roots — Weir-Mitchell  treatment 
must  be  tried  after  removal  of  all  cause  for  worry.  It  is  useless  treating 
advanced  cases  while  compensation  proceedings  are  pending.  Weir-Mitchell 
treatment  must  also  be  adopted  after  operation  in  the  cases  complicated  by 
hysteria.  When  muscular  symptoms  are  present,  the  affected  muscles  must 
be  kept  relaxed  by  suitable  apparatus,  and  daily  massage  given  until  voluntary 
power  returns.     It  is  often  twelve  months  before  muscular  recovery  is  complete. 

Special  Nerves. 

Facial. — The  nerve  may  be  injured  as  the  result  of  fracture  of  the  base  of  the 
skull  primarily  or  from  involvement  in  callus,  and  during  the  course  of  mastoid 
operations,  during  operations  in  the  parotid  or  submaxillary  regions,  or  from 
forceps  pressure  during  childbirth. 

When  injured  as  the  result  of  fracture,  whether  involved  primarily  or 
secondarily,  the  division  is  usually  incomplete,  and  perfect  recovery  ensues 
in  about  three  months.  Facial  paralysis  following  operation  on  the  middle 
car  is,  as  a  rule,  due  to  incomplete  division.  Spontaneous  recovery  is  usual 
in  the  majority  of  cases,  but  may  take  twelve  months.  The  incomplete  facial 
paralysis,  which  may  occur  as  the  result  of  operations  in  the  submaxillary 
region,  is  rarely  permanent  if  the  wound  heals  by  first  intention. 

Careful  electrical  testing  is  necessary  in  order  to  enable  an  opinion  to  be  given 
with  regard  to  the  necessity  of  operative  treatment.  If  true  reaction  of 
degeneration  develops,  no  time  should  be  lost,  but  operation  carried  out. 

In  but  few  cases  is  it  possible  directly  to  unite  the  divided  ends  of  the  nerve, 
.and  nerve  anastomosis   is  neccssarv. 


374  INDEX     OF     PROGNOSIS 

The  best  results  are  given  when,  as  first  suggested  by  Korte/'  the  hypo- 
glossal is  used  and  the  anastomosis  is  of  the  partial  peripheral  type.  The 
prognosis  varies  with  the  cause  of  the  paralysis,  being  better  when  the  division 
results  from  injury  than  when  it  is  the  result  of  neuritis.  Suppuration  of  the 
operation  wound  renders  success  doubtful. 

The  first  sign  of  recovery  usually  appears  about  the  third  or  fourth  month, 
the  face  while  at  rest  becoming  more  symmetrical,  although  there  is  no  return 
of  voluntary  power.  A  few  weeks  later  it  is  noticed  that  the  angle  of  the  mouth 
can  be  moved,  at  first  only  with  movements  of  the  tongue  ;  then  the  muscles 
of  the  upper  lip,  and  finally  those  of  the  forehead.  With  exercise,  the  move- 
ments become  dissociated,   and  finally  emotional  movement  may  return. 

For  a  few  weeks  after  operation,  the  side  of  the  tongue  is  paralyzed,  causing 
difficulty  in  speech  and  deglutition  ;  this  passes  off,  but  the  affected  side  of 
the  tongue  may  remain  smaller  for  a  considerable  time. 

In  40  cases  collected  by  the  writer,  improvement  occurred  in  all  reported 
at  a  sufficiently  late  date  ;  but  in  comparatively  few  did  emotional  movement 
return,  the  face  on  the  side  of  the  injury  remaining  immobile  in  smiling.  It 
is  safe  to  say  that  in  the  majority  of  cases  the  appearance  of  the  face  at  rest 
will  become  normal. 

Recurrent  Laryngeal  Nerve. — This  nerve  is  not  infrequently  injured  in 
operations  upon  the  thyroid  gland.  The  paralysis  is  usually  temporary,  and 
disappears  within  three  months.  If  at  the  end  of  that  time  recovery  has  not 
taken  place,  operation  offers  a  good  chance  for  recovery.  In  the  first  case  of 
secondary  suture  recorded  (Shelton  Horsley^^),  recovery  was  almost  perfect 
fifteen  months  later. 

Brachial  Plexus. — It  is  now  well  established  that  the  prognosis  of  injuries 
to  the  brachial  plexus,  taken  as  a  whole,  is  worse  than  those  elsewhere,  although, 
as  noted  by  Bardenheuer,*^  and  more  recently  by  Winnen,'"  the  seriousness 
has  been  exaggerated. 

Von  Bruns^^  found  that  while  spontaneous  recovery  ensued  in  66  per  cent 
of  subcutaneous  injuries  of  peripheral  nerves,  only  26  per  cent  of  similar  plexus 
injuries  got  well  spontaneously.  Warrington  and  Jones,-'-  from  the  examination 
of  cases  under  their  care,  found  spontaneous  recovery  in  30  to  40  per  cent. 
Winnen  30  per  cent,  with  70  per  cent  improvement.  These  unfavourable 
figures  are  due  in  part  to  the  nature  of  the  injury.  In  a  large  proportion  of 
cases  the  nerves  are  overstretched,  and  this  results  in  haemorrhage  into  the 
sheath  and  consequent  fibrosis  ;  in  addition,  if  it  leads  to  rupture,  the  fibres 
give  way  at  different  levels  ;  hence  spontaneous  recovery  is  unusual  when  the 
signs  of  complete  division  are  present,  and  is  apt  to  be  imperfect  in  cases  of 
incomplete  division.  Again,  it  is  possible  that  the  injury  in  some  cases  tears 
the  roots  away  from  the  cord.  Even  after  operation,  the  prognosis  is  not  so 
good  as,  for  example,  after  secondary  suture  of  the  median  at  the  wrist  or  the 
musculospiral.  This  has  to  do  to  a  great  extent  with  the  length  of  time  neces- 
sary to  complete  recovery  ;  in  many  cases  the  patient  ceases  to  attend  for 
efficient  after-treatment,  and  when  recovery  of  the  nerve  has  finally  become 
complete,  the  muscles  are  atrophic,  and  contractures  of  the  opponent  muscle 
render  the  regeneration  of  the  nerve  futile. 

Brachial  Birth  Paralysis. — The  prognosis  is  favourable  if  efficient  treatment 
is  adopted  from  the  time  of  birth.  Nerve  recovery  has  taken  place  in  70  per 
cent  of  the  cases  under  my  care  ;  but  in  these  lesions  particular  care  is  necessary 
in  order  to  prevent  over-stretching  of  the  paralyzed  muscles  and  over-action 
of  their  opponents.  Unless  this  is  carefully  attended  to,  although  the  nerve 
recovers  completely,   the  child  is  Jeft  with  a  damaged  limb.     This  point  has 


NERVE     INJURIES  375 


recently  been  emphasized  by  Fairbank,-^  who  has  devised  an  eificient  splint 
for  the  purpose. 

With  regard  to  operation  :  this  is  necessary  in  a  minority  of  cases.  If  at 
the  end  of  three  months  from  birth  the  reaction  of  degeneration  is  present, 
operation  should  be  carried  out  as  soon  as  convenient.  If  it  is  possible  to 
excise  the  damaged  portion  of  nerve  and  perform  end-to-end  suture,  the  outlook 
is  favourable  ;  but  when  this  is  impossible  and  nerve  anastomosis  becomes 
necessary,  perfect  recovery  is  unlikely  to  take  place. 

Post-ancesthetic  Brachial  Paralysis. — These  injuries  of  the  plexus  are  by  no 
means  uncommon,  although  published  cases  are  few.  Cotton  and  Allen,-** 
in  1903,  were  only  able  to  collect  30  from  the  literature.  It  occurs  in  patients 
in  whom,  during  the  course  of  operation,  the  arms  are  abducted  and  externally 
rotated  or  raised  above  the  head.  The  right  arm  is  usually  affected.  Stretching 
over  the  head  of  the  humerus  with  the  arms  elevated  above  the  head  is  the 
probable  cause  of  the  infraclavicular  injuries.  In  all  cases  the  lesion  is  incom- 
plete, corresponding  to  the  slight  violence  which  produced  it. 

The  prognosis  is  good  ;  all  the  cases  that  I  have  had  under  observation  have 
recovered  completely  without  surgical  intervention,  and  all  except  one  of  those 
collected  by  Cotton  and  Allen. 

Injury  due  to  Presence  of  a  Cervical  Rib. — A  cervical  rib  is  by  no  means  an 
unusual  cause  of  injury  to  the  brachial  plexus  as  the  result  of  long-standing 
pressure.  In  cases  in  which  the  nervous  symptoms  are  marked,  removal  of  the 
rib  is  the  only  treatment.  The  result  of  this  is  on  the  whole  good.  As  in  other 
cases  in  which  muscles  are  affected  as  the  result  of  prolonged  nerve-pressure, 
the  question  of  perfect  recovery  will  depend  upon  the  extent  of  the  wasting 
and  deformity  produced.  When  this  is  well  marked,  some  atrophy  and  deformity 
of  fingers  always  remain. 

The  nervous  symptoms  fall  into  two  groups,  paralytic  and  neuralgic.  As 
a  rule  these  co-exist.  The  subject  has  been  fully  discussed  at  the  Royal  Society 
of  Medicine.-*  Thorburn  reported  20  cases  (14  personal),  and  came  to  the 
conclusion  that  pain  was  relieved  in  four-fifths  ;  paralysis  cured  in  certainly 
one-half.  Sargent,  as  the  result  of  operation  on  29  cases,  speaks  of  "  the  most 
gratifying  immediate  results  obtained  in  those  cases  in  which  pain  had  been  the 
prominent  feature."  Hinds  Howell  collected  the  after-results  in  25  cases,  and 
came  to  the  conclusion  that  "  in  the  majority  of  cases  pain  will  be  reheved  or 
cured.  With  regard  to  muscular  weakness  and  atrophy,  the  expectation  is  that 
the  operation,  if  it  is  not  too  long  delayed,  will  greatly  improve  the  condition." 
(See  Cervical  Rib.) 

It  was  pointed  out  that  a  paralysis  of  the  brachial  plexus  may  occasionally 
occur  as  the  result  of  operation,  but  if  performed  by  those  skilled  in  the  procedure 
is  unusual  and  transient. 

Operative  treatment  undoubtedly  removes  the  most  distressing  symptom  of 
this  condition. 

Circumflex  Nerve. — Injury  to  this  nerve  is  unusual,  and  is  usually  subcutaneous 
the  result  of  pressure  of  the  dislocated  head  of  the  humerus  or  a  crutch,  and 
results  in  an  incomplete  physiological  division.  Treated  on  the  usual  lines, 
recovery  ensues  as  a  rule,  but  is  generally  slow.  Even  if  the  paralysis  persists, 
operation  is  not  often  necessary,  for  the  supinators  and  clavicular  fibres  of  the 
pectoralis  major  acting  with  the  trapezius  may  compensate  for  its  loss. 

Ulnar  Nerve. — The  prognosis  in  cases  of  injury  to  the  ulnar  nerve  depends 
upon  the  care  taken  to  prevent  the  development  of  claw-hand.  If  in  cases  of 
incomplete  division  or  after  primary  suture  a  suitable  splint  is  worn,  perfect 
recovery  may  take  place,  although  it  is  unusual  in  the  latter. 


376  INDEX     OF     PROGNOSIS 

Perfect  recovery  never  ensues  after  secondary  suture,  or  releasing  the  nerve 
from  pressure  in  case  of  injury  the  result  of  old  deformity  of  the  elbow  or  long- 
standing dislocation.  Some  weakness  of  the  intrinsic  muscles  of  the  hand  always 
remains. 

Musculospiral  Nerve. — The  prognosis  is  more  favourable  than  after  injury 
of  any  other  nerve.  It  supplies  no  important  area  with  sensibility,  its  muscles 
are  none  of  them  intrinsic.  Most  of  its  injuries  are  subcutaneous,  resulting 
in  incomplete  physiological  division.  If  treated  by  relaxation  of  the  paralyzed 
muscles,  recovery  is  rapid,  and  usually  perfect  within  three  months.  ■V\Tien 
operative  treatment  is  necessary  to  free  the  nerve  from  injurious  pressure, 
restoration  of  function  usually  commences  in  a  few  weeks.  After  secondary 
suture,  motor  power  usually  returns  in  nine  to  twelve  months,  and  perfect  use 
is  regained  within  eighteen. 

References.  ^Traite  des  Sections  Nerveuses,  Paris,  1873;  -Jour.  Physiology,  xiv. ; 
^Injuries  and  Diseases  of  Nerves,  London,  1889  ;  *Brain,  Summer  No.  1905,  ex ; 
^Lancet,  1906,  Mar.  17,  24,  31  ;  ^Zentr.  f.  Chir.  1913,  No.  3r,  s.  1222  ;  ''Loc.  cit.  ; 
^Brit.  Med.  Jour.  1904,  ii,  1065  ;  ^Lancet,  1902,  ii,  198  ;  ^'^Brit.  Med.  Jour.  1871,  ii,  640  ; 
^^Bull.  et  Mem.  de  la  Soc.  de  Chir.  1905,  xvu,  471  ;  ^-Trans.  Roy.  Med.  and  Chir. 
Sac.  1902,  290  ;  ^^Phil.  Trans.  Roy.  Soc.  1897,  188  B.  257  ;  ^^Edin.  Med.  Jour.  Oct. 
1906  ;  ^^Ann.  Surg.  1904,  xl,  632  ;  ^^Archiv.  gen.  de  Med  1905,  No.  11  ;  ^''Deut.  med. 
Woch.  1903,  No.  17 ;  ^^Ann.  Surg.  1910,  i,  524  ;  ^^Archiv.  f.  Chir.  1909,  Bd.  89  ; 
^°Deut.  Zeits.  f.  Chir.  Bd.  118,  1912,  s.  416  ;  ^^Neurol.  Centr.  1902,  s.  1042  ;  ^^Lancet, 
1906,  ii,  1644  ;  ^^Ihid,  1913,  i,  1219  ;  ^^Boston  Med.  and  Surg.  Jour.  1903,  cxlviii,  499; 
^'Proc.  Roy.  Soc.  Med.  1913,  vi.  No.  5,  Clin.  Sect.  113-127-  James  Sherren. 

NEURALGIA,  TRIGEMINAL. — We  shall  only  consider  here  the  prognosis 
of  the  severest  form  of  neuralgia,  tic  douloureux,  and  shall  assume  that  ordinary 
medical  treatment,  and  the  examination  of  the  teeth,  nasal  accessory  sinuses, 
etc.,  has  proved  abortive.  The  neuralgia  is  severe  in  character,  comes  on  in 
occasional  paroxysms,  and  shows  no  tendency  to  spontaneous  cure. 

The  methods  of  treatment,  then,  with  which  we  have  to  do,  are  (i)  The 
peripheral  neurectomies  ;  (2)  Alcohol  injection  ;  and  (3)  The  removal  of  the 
Gasserian  ganglion  by  the  Hartley- Krause  method. 

1.  The  Peripheral  Neurectomies,  such  as  removal  of  a  piece  of  the  lingual  and 
inferior  dental  nerves,  excision  of  the  infra-orbital  nerve,  or  the  Braun-Lossen 
operation  on  the  second  division  of  the  trigeminal  nerve,  are  all  comparatively 
safe,  so  far  as  the  immediate  risk  to  life  is  concerned  ;  they  have  the  very  serious 
drawback  that  permanent  cure  by  their  means  is  most  exceptional ;  and  when 
it  does  occur,  it  is  always  open  to  suspicion  that  some  peripheral  dental  or  other 
cause,  capable  of  simple  treatment,  has  been  overlooked.  Out  of  43  cases 
treated  by  neurectomy,  the  average  duration  of  relief  from  pain  was  ten  months 
(Putnam  and  Waterman). 

2.  Alcohol  Injection  into  the  Gasserian  ganglion  is  somewhat  difficult  of 
technique,  and  it  may  not  be  possible  to  reach  the  desired  spot ;  but  it  appears 
to  be  perfectly  safe,  so  far  as  risk  to  life  is  concerned.  Even  if  the  injection  is 
made  by  mistake  into  the  subdural  space,  nothing  worse  than  a  headache  results. 
The  relief  given,  if  the  alcohol  can  be  correctly  placed,  is  very  marked,  and  lasts 
for  a  long  time,  even  if  it  is  not  permanent ;  there  is  usually  complete  freedom 
from  pain  for  many  months  or  years.  Harris  was  able  to  give  this  relief  in  80 
out  of  86  cases.  The  test  of  success  is  the  production  of  immediate  anaesthesia 
in  the  whole  distribution  of  the  fifth  nerve.  The  injection  can  be  repeated,  if 
recurrence  takes  place,  with  equally  good  results. 

Hartel  followed  up  25  cases,  15  for  more  than  six  months  ;  of  these  15,  9  were 
free  from  pain  and  6  relapsed.  A  serious  trouble  is  that  keratitis  may  result  ; 
this  took  place  in  6  out  of  the  25  patients,  and  one  eye  had  to  be  enucleated. 
Possibly  covering  the  eye  may  give  better  success. 


NEURITIS  377 

Removal  of  the  Gasserian  Ganglion  is,  no  doubt,  a  serious  operation,  but  the 
mortality,  in  skilful  hands,  is  not  as  high  as  is  commonly  supposed.  Horsley, 
Hutchinson,  and  Krause  together  report  a  death-rate  of  4  per  cent.  Some  years 
ago,  Horsley  had  operated  on  120  patients  with  6  deaths.  Rawling  puts  the 
mortality  at  5  per  cent.  Very  possibly  it  may  be  higher  in  the  practice  of  those 
who  have  seldom  or  never  performed  the  operation. 

The  rehef  appears  to  be  certain,  complete,  and  permanent. 

Here  again  there  may  be  trouble  with  the  eye.  Hartel  shows  that  keratitis  has 
followed  in  30  out  of  207  successful  removals  of  the  ganglion,  that  is,  about  15 
per  cent. 

References. — Harris,  Lancet,  1912,  i,  21S  ;  Hartel,  Deul.  Zeits.  f.  Chir.  1914, 
xxvi,  429.  ^.  Renile  Short. 

NEURITIS. — There  are  two  great  groups  into  which  cases  of  neuritis  are 
classified  : — (i)  Multiple  or  peripheral  neuritis,  where  many  or  all  of  the  peri- 
pheral nerves  are  involved  ;  (2)  Local  neuritis,  where  only  a  single  nerve,  or 
portion  of  a  nerve,  is  affected. 

I.  Multiple  Neuritis  or  Polyneuritis. — In  most  cases  this  is  due  to  some  poison. 
This  poison  may  be  introduced  from  without,  as  in  the  cases  of  alcohol,  arsenic, 
lead  or,  less  commonly,  mercury,  phosphorus,  or  copper  ;  or  it  may  be  the  result  of 
micro-organisms  producing  specific  diseases,  or  of  their  toxins,  as  in  diphtheria, 
influenza,  malaria,  septicasmia,  gonorrhoea,  beri-beri,  leprosy,  syphilis.  Multiple 
neuritis  may  also  be  produced  by  poisons  arising  within  the  bod3%  as  in  diabetes, 
pregnancy,  etc. 

Of  these  varieties,  the  commonest  of  all  is  alcoholic  polyneuritis.  It  is 
unnecessary  to  describe  the  clinical  features  of  this  disease.  Its  onset  is  insidious, 
and  the  symptoms  may  take  weeks  or  months  to  attain  their  maximum  intensity. 
If  the  alcoholic  habit  continues,  the  neuritis  persists  indefinitely,  until  the  patient 
becomes  bedridden ;  contractures  of  the  limbs  develop,  especially  in  the  feet ; 
and  the  patient  dies,  sooner  or  later,  from  some  intercurrent  malady,  usually  of 
pulmonary  origin.  If  however,  the  poison  be  withdrawn,  and  if  massage  and 
electrical  treatment  are  then  assiduously  carried  out,  the  symptoms  may  even 
continue  to  increase  for  two  or  three  weeks,  before  coming  to  a  standstill.  There 
is  then  usually  a  stationary  period  of  one  or  two  months  before  signs  of  improve- 
ment begin  to  appear.  Then  the  pains  and  the  hypersesthesia  gradually  diminish, 
the  cutaneous  anaesthesia  clears  up,  and  the  motor  paralysis  recovers  in  from  four 
to  six  months  from  the  time  of  onset  of  improvement ;  the  proximal  muscles 
recover  before  the  distal.  Last  of  all,  the  deep  reflexes  return  ;  a  patient  may 
have  complete  sensory  and  motor  recovery  for  weeks  or  months  before  the  deep 
reflexes  reappear. 

The  prognosis  as  to  life,  in  a  case  of  multiple  neuritis  from  any  cause,  depends 
on  various  factors.  The  motor,  rather  than  the  sensory,  symptoms  are  of  signifi- 
cance in  this  respect:  The  more  rapid  the  onset  of  paralytic  symptoms,  the 
more  dangerous  is  the  case.  When  the  symptoms  have  attained  a  considerable 
severity  within  a  few  days,  there  is  a  grave  risk  of  extension  to  the  respiratory 
muscles.  Implication  of  the  diaphragm  and  intercostals  greatly  increases  the 
seriousness  of  the  case,  more  especially  if  the  cardiac  muscle  be  enfeebled, 
as  is  so  often  the  case.  Patients  with  multiple  neuritis  have  a  particularly 
feeble  power  of  resistance  to  pulmonary  infections,  whether  by  the  tubercle 
bacillus,  the  pneumococcus,  or  other  organisms  ;  and  the  presence  of  lung 
complications,  even  a  simple  bronchitis,  is  always  a  serious  matter  in  such 
patients. 

A  characteristic  form  of  mental  affection,  known  as  Korsakow's  psychosis, 
occurs  in  some  cases  nf  polyneuritis.     Its  symptoms  arc  those  of  mild  mental 


378  INDEX     OF     PROGNOSIS 

confusio-i,  especially  with  regard  to  times  and  places,  together  with  impairment 
of  memory  for  recent  events  ;  so  that  a  patient  who  is  bedridden  from  polyneur- 
itis may  give  descriptions  of  recent  long  walks  which  she  has  taken  (the  patient  is 
iisually  a  woman),  and  of  the  various  people  and  places  whom  she  has  thus 
visited. 

The  nature  of  the  poison  which  produces  the  multiple  neuritis  has  little  or  no 
influence  per  se  upon  the  prognosis  as  to  recovery.  The  different  forms  of 
polyneuritis  run  a  similar  course.  A  great  deal,  however,  depends  on  whether 
the  source  of  the  underlying  poison,  once  it  is  recognized,  has  already  been 
removed,  as  in  diphtheria  or  septicaemia  ;  whether  it  can  be  cut  off  with 
ease,  as  in  lead  or  arsenic ;  whether  there  is  a  tendency  to  relapse,  as  in 
alcohol ;  or  finally,  whether  it  cannot  be  removed,  as  in  diabetes,  cancer, 
lepros}^,   etc. 

2.  Local  Neuritis. — Recognition  of  the  underlying  cause,  and  its  removal,  if 
possible,  are  the  first  essentials  in  every  case  of  local  neuritis.  Thus,  in  a  neuritis 
due  to  local  pressure  (e.g.,  by  crutches,  callus  from  an  old  fracture,  cervical  ribs, 
tumours,  etc.)  the  underlying  cause  can  sometimes  be  removed.  In  other  cases, 
the  exciting  cause  has  already  produced  its  effect  on  the  nerve-trunk,  and  we 
have  to  deal  with  the  result  (e.g.,  in  local  neuritis  due  to  bruising  or  inflammation 
of  the  nerve,  or  to  exposure  to  cold).  In  other  cases  still,  we  have  to  do  with  a 
disease  which  produces  a  primary  degeneration  of  the  nerve-fibres  (e.g.,  in 
diabetes,  malaria,  enteric  fever).  In  a  still  further  class,  the  fibrous  tissues  of  the 
nerve-trunk,  its  sheath  or  perineurium,  are  primarily  attacked,  and  the  degenera- 
tive changes  are  secondary  (e.g.,  in  gouty,  syphilitic  and  leprous  neuritis).  The 
prognosis,  therefore,  of  any  individual  case  of  localized  neuritis  is  that  of  its 
underlying  cause. 

Electrical  Reactions. — In  cases  of  local  neuritis  of  a  mixed  nerve,  where  both 
sensory  and  motor  phenomena  are  present,  sensory  functions  generally  recover 
before  motor,  although  this  rule  is  not  without  its  exceptions.  With  regard  to 
motor  paralysis,  the  prospects  of  recovery  are  best  estimated  by  a  careful  study 
of  the  electrical  reactions.  To  niake  an  accurate  prognosis,  however,  the  motor 
paralysis  must  have  lasted  at  least  ten  days,  to  allow  time  for  degenerative 
changes,  if  any,  to  have  developed.  If,  after  ten  da3^s  or  a  fortnight  of  motor 
paralysis,  we  find  the  typical  '  reactions  of  degeneration ' — i.e.,  total  loss  of 
faradic  excitability,  with  reversed  polar  reactions  and  a  slow  sluggish  response 
to  galvanism, — the  degeneration  of  the  nerve-fibres  is  complete,  and  recovery  will 
not  commence  for  three  months  at  least,  possibly  not  for  a  year;  and  even  then, 
if  recovery  ultimately  sets  in,  it  will  probably  be  imperfect  and  associated  with 
a  certain  amount  of  contracture.  If,  on  the  other  hand,  the  electrical  reactions 
are  normal  to  faradism  and  galvanism,  or  if  there  be  merely  a  quantitative 
diminution,  without  polar  changes,  recovery  may  be  expected  to  begin  in  from 
three  to  six  weeks  from  the  onset  of  the  paralysis.  Sometimes  we  meet  with 
partial  or  incomplete  reactions  of  degeneration,  consisting  in  a  sluggish  contrac- 
tion to  galvanism,  with  reversed  polar  reactions,  but  with  preservation  of  a  certain 
amount  of  faradic  response.  In  such  cases,  we  may  expect  improvement  in  from 
six  to  eight  weeks  from  the  onset  of  the  paralysis.  Examination  of  the  reaction 
of  the  muscles  to  condenser  discharges  is  a  valuable  addition  to  faradic  and 
galvanic  stimulation  as  a  means  of  electro-diagnosis  and  prognosis.  A  healthy 
striated  muscle-fibre  reacts  to  condenser  shocks  of  the  smallest  condensers 
(e.g.,  ooi  to  OI2  microfarad),  with  the  shortest  and  fastest  wave-lengths  ; 
whereas  a  degenerated  muscle  requires  larger  condensers  (e.g.,  0-50,  i-oo,  2-00, 
or  even  S'oo   microfarads),   with   longer   and   slower   wave-lengths. 

Purees  Stewart. 


(ESOPHAGUS,     STRICTURE     OF  379 


(EDEMA,  MALIGNANT. — This  disease,  one  form  of  the  old-fashicned 
Hospital  Gangrene,  used  to  exact  a  frightful  toll  in  the  pre-antiseptic  era.  The 
term  should  be  reserved  for  cases  of  spreading  gangrene  following  on  a  wound, 
with  gas-bubbles  in  the  tissues,  due  to  Welch's  Bacillus  aerogenes  capsulatns, 
or  the  Bacillus  oedematis  nialigni. 

According  to  Welch,  the  prognosis  is  not  as  absolutely  hopeless  as  might 
be  imagined.  If  an  early  high  amputation  is  performed,  about  40  per  cent 
of  the  patients  may  be  saved.  In  1898  the  mortality  was  given  as  95  per  cent. 
When  the  gangrene  is  extensive  and  the  patient  looks  poisoned,  the  outlook 
is  very  grave  indeed,  and  death  will  probably  ensue  in  a  day  or  two. 

The  surgical  experiences  of  the  Great  War  have  thrown  new  light  upon  our 
conceptions  of  this  disease,  which  has  unfortunately  been  common  amongst 
wounded  lying  out  long  without  treatment,  and  especially  if  earth  infection 
took  place.  When  the  condition  is  still  localized,  and  there  is  a  blackened, 
emphysematous  area  close  to  the  wound  but  not  far  up  the  limb,  it  can  be 
checked  in  many  cases  by  injections  of  oxj'gen  bubbles  through  a  needle,  and 
the  application  of  hydrogen  peroxide.  When,  however,  a  larger  area  than  the 
palm  of  the  hand  is  affected,  amputation  is  usually  required,  and  the  best 
results  are  obtained  if  the  flaps  are  left  open.  It  is  too  soon  yet  to  present 
the  relative  value  of  methods  in  statistical  form.  Haycraft  reports  that  of  21 
wounded  soldiers  treated  by  amputation,  only  5  died,  and  in  4  cases  incision 
and  drainage  was  sufficient  to  save  life. 

Reference. — Haycraft,  Lancet,  19 15,  i,  592.  A.  Rendle  Short. 

(ESOPHAGUS,  STRICTURE  OF. — Stricture  of  the  oesophagus  may  be — 
(i)  Functional  {cardiospasm)  ;  (2)  Simple,  usually  due  to  scar-contraction  after 
swallowing  a  corrosive  ;    (3)  Malignant. 

1.  Cardiospasm,  a  condition  in  which  the  entrance  into  the  stomach  is  tightly 
contracted,  whilst  the  oesophagus  above  may  be  hugely  distended,  is  rare.  It 
may  be  recognized  by  the  oesophagoscope,  and  by  a  skiagram  after  a  bismuth 
meal.  It  persists  for  years,  apart  from  treatment,  and  shows  no  tendency  to 
spontaneous  cure.  Dilatation,  by  various  complicated  means,  usually  gives 
a  good  result. 

2.  Simple  Stricture,  due  to  scarring,  may  be  recognized  by  the  history,  by 
skiagram,  by  the  failure  to  admit  a  bougie,  and  by  the  glistening  white  appear- 
ance without  ulceration  seen  with  the  oesophagoscope.  At  least  9  out  of  10  of 
the  cases  can  be  dilated  up  by  bougies,  passed,  if  necessary,  by  the  aid  of  the 
oesophagoscope.  If  this  fails,  a  temporary  gastrostomy  will  often  allow  of 
successful  retrograde  catheterism  ;  or,  in  a  week  or  two,  the  rest  to  the  oesophagus 
allows  of  a  bougie  being  passed.  Dilatation  of  the  stricture  has  to  be  kept  up 
for  many  years  at  regular  intervals.  Oser  reports  on  the  cases  treated  at  Vienna 
during  the  past  ten  years.  Out  of  47  patients,  27  were  treated  by  dilatation, 
with  21  cures  and  i  death  ;  14  by  gastrostomj^  and  retrograde  catheterism, 
with  10  cures  and  i  death  ;  6  by  gastrojejunostomy,  etc.  (for  burns  of  stomach), 
with  5  cures  and  no  deaths  ;    the  other  patients  were  improved,  or  lost  sight  of. 

3.  Malignant  Stricture,  of  course,  has  a  hopeless  outlook.  Apart  from  gastro- 
stomy, the  duration  of  life  is  usually  not  more  than  six  months  from  the  onset 
of  dysphagia  ;  that  operation  prolongs  life  a  few  months.  A  good  many  deaths, 
and  one  success,  have  followed  excision  of  the  growth. 

Reference. — Surg.  Gyn.  and  Obst.,  Abstract,  1913,  xvi,  17. 

A.  Rendle  Short. 

ORCHITIS,   TUBERCULOUS.— (See  Epididymitis,  Tuberculous.) 


38o  INDEX     OF     PROGNOSIS 

OSTEITIS  DEFORMANS  (PAGET'S  DISEASE).— Of  this  rare  disease  there 
are  not  many  more  than  a  hundred  cases  recorded,  but  most  surgeons  of  experi- 
ence can  recollect  one  or  two  others  which  have  not  found  their  waj'  into  print. 
It  is  a  chronic  incurable  affection  which  may  not  shorten  life. 

The  strange  feature  of  the  prognosis  is  the  considerable  probability  that  a 
malignant  bony  growth  will  eventually  appear.  Of  34  cases  followed  to  their 
termination,  this  was  the  cause  of  death  in  12. 

Reference. — Elmslie,  St.  Barfs.  Hosp.  Rep.  igo8,  121.  A..Rendle  Short. 

OSTEOMALACIA. — This  disease  appears  to  be  more  commonly  met  with 
on  the  Continent  than  in  England  or  America.  It  affects  young  women  for 
the  most  part,  though  a  few  cases  are  recorded  in  males  and  in  children.  The 
outlook  is  very  grave.  According  to  the  older  authorities,  it  goes  on  in  most 
cases  to  a  fatal  termination  in  from  two  to  ten  years,  the  patient  being  bedridden 
most  of  the  time.  Durham  records  22  out  of  145  cases  in  which  natural  recovery, 
more  or  less  complete,  was  observed.  It  is  most  unfavourably  influenced  by 
pregnancy,  and  is  often  first  recognized  at  that  time.  As  is  well  known,  the 
pelvis  becomes  very  contracted,  and  Caesarean  section  will  probably  be  required. 
The  child  is  normal.     Many  of  the  mothers  have  died  in  childbirth. 

In  a  small  number  of  cases,  double  oophorectomy  has  been  performed,  and  there 
is  some  evidence  that  this  improves  the  outlook.  Fehling  reports  14  cases  : 
6  of  these  were  cured  for  three  years  or  more  ;  2  were  better  for  a  time  and  then 
relapsed  ;  the  rest  died  or  were  lost  sight  of.  Other  observers  have  recorded 
temporary  benefit  with  relapse  following. 

There  are  a  few  cases  known  in  which  great  benefit  followed  adrenalin  injections. 

References. — Durham,  Guy's  Hosp.  Rep.  x.  1064  ;  Kaipe,  Amer.  Jour,  of  Obstet. 
1912,  Ixv.  582.  ^,  Rendle  Short. 

OSTEOMYELITIS. — It  is  not  easy  to  estimate  the  prognosis  of  such  a  disease 
as  this  in  formal  terms,  for  any  bone  may  be  affected,  and  with  every  degree 
of  severity. 

Prognosis  as  to  Life. — In  man}'  cases  there  is  very  considerable  danger  to 
life.  The  rare  infections  of  the  skull  and  vertebral  column  are  very  fatal,  and 
the  majority  of  young  children  with  perforation  into  the  joint  (Sir  T.  Smith's 
Acute  Arthritis  of  I^ifants)  also  die. 

Even  with  the  commoner  affections  of  the  long  bones  there  is  grave  risk. 
During  the  years  igot  to  1910,  at  the  London  Hospital,  34  per  cent  of  the 
patients  died  ;  the  usual  causes  of  death  were  endo-  or  pericarditis,  empyema, 
or  abscess  of  the  lung.     Others  die  of  cachexia  at  a  later  date. 

Signs  of  danger  are — extension  of  the  infection  over  the  whole  length  of  a 
large  bone  such  as  the  femur  or  tibia,  multiple  bone  involvement,  rigors,  and 
signs  of  trouble  in  the  chest.  In  chronic  cases,  great  wasting  and  cachexia, 
apart  from  efficient  treatment,  point  to  a  probably  fatal  termination. 

The  3-ounger  the  patient  the  graver  the  outlook.  Early  and  thorough 
surgical  intervention  is  of  the  utmost  importance  in  the  acuter  types  of 
the  disease. 

Prognosis  as  to  Limb. — Very  early  operation,  laying  open  the  whole  infected 
area,  will  avert  the  long  illness  which  necrosis  necessarily  involves.  Unfortunately 
the  surgeon  is  generally  too  late,  and  part  of  the  bone  will  die.  In  the  worst 
cases,  the  periosteum  is  rapidly  stripped  up  and  the  osteoblasts  are  killed,  so 
that  no  regeneration  of  bone  will  take  place.  This  is  the  rule  in  necrosis  of  the 
lower  jaw.  Usually,  however,  an  efficient  new  bone  is  formed  in  time  ;  but  it 
takes  months  for  the  sequestrum  to  separate,  and  again,  after  that  is  removed. 


OVARIAN     TUMOURS  381 


for  the  sinuses  to  close.  It  is  likely  to  be  from  six  months  to  a  year  or  more 
before  the  patient  is  well. 

Necrosis  of  the  popliteal  plate  of  the  femur  is  a  very  trying  condition  for  all 
concerned,  as  the  separation  of  the  sequestrum  may  take  an  interminable  time. 
Many  of  the  cases  are  cut  short,  at  last,  by  an  amputation,  on  account  of  failure 
of  the  general  health. 

Reference. — Kennedy,  Brit.  Med.  Jour.  1912,  ii,  114.  A.  Rendle  Short. 

OVARIAN  TUMOURS. — The  prognosis  in  ovarian  tumours  is  very  largely 
dependent  upon  the  nature  of  the  growth.  With  the  exception  of  certain 
adventitious  accidental  phenomena  which  we  shall  consider  later,  the  outlook 
is  good,  doubtful,  or  bad  according  to  the  histological  characters.  At  the  outset, 
it  cannot  be  too  definitely  asserted  that  naked-eye  characters  alone  are  an 
insufficient  guide  ;  and  in  no  region  of  pathology  are  the  services  of  ah  expert 
histologist,  experienced  in  the  study  of  ovarian  tumours,  more  valuable  than 
in  expressing  an  opinion  upon  such  a  growth  ;  even  under  the  microscope,  there 
are  certain  cystic-solid  tumours  on  which  it  is  difficult  to  express  a  decided 
opinion. 

The  relative  proportion  of  benign  to  malignant  tumours  varies  considerably  ; 
thus  Macnaughton-Jones^  collected  the  figures  from  German  clinics,  and  in  a 
series  of  2893  cases  only  11  per  cent  were  reported  as  malignant;  while  Mrs. 
Scharlieb^  found  i6-6  per  cent  malignant  out  of  150  cases,  and  Glendining* 
found  17  per  cent  carcinomatous  out  of  106  cases  occurring  in  the  Chelsea 
Hospital  for  Women  in  the  years  1908  and  1909. 

From  the  point  of  view  of  prognosis,  we  have  always  been  in  the  habit  of 
dividing  ovarian  tumours  into  three  groups  :  (i)  The  simple  (forming  the 
largest)  ;     (2)   The  semi-malignant ;    and   (3)    The  malignant. 

1.  The  Simple. — In  the  simple  unilocular  ovarian  cysts,  the  results  of  operation 
are  good  :  probably  there  is  no  more  uniformly  successful  operation  in  surgerj^-. 
A  small  proportion  of  cases  have  to  be  opened  up  again  owing  to  slipping  of 
the  ligature  round  the  pedicle,  and  occasionally  such  a  case  is  lost.  This  accident 
usually  results  from  ligaturing  a  large  pedicle  together  with  a  piece  of  the  broad 
ligament,  so  that  when  the  uterus  is  pulled  on  or  displaced,  a  portion  of  the 
ligated  tissues  tends  to  be  withdrawn.  A  more  remote  accident  occasionally 
follows  failure  to  bury  the  stump  of  the  pedicle  ;  in  such  a  case  the  sequence  of 
events  is  the  formation  of  a  band,  the  passing  of  gut  under  the  band  as  in  hernia, 
and  eventual  strangulation. 

2.  The  Serai-malignant. — This  variety  comprises  those  ovarian  tumours 
known  as  proligerous  cystadenomata  and  papuliferous  ovarian  cysts.  In  these 
cases,  the  chief  difficulty  arises  in  excluding  malignancy,  as  many  of  thenx 
simulate  columnar-cell  carcinoma  very  closely.  They  are  here  distinguished 
from  the  properly  malignant  cysts  because  they  do  not  show  true  metastases  : 
secondary  masses  are  the  result  of  contact  implantation  ;  they  are  practically 
never  found  outside  the  abdominal  cavity  unless  they  occur  in  the  scar  of  an 
abdominal  incision  ;    and  they  do  not  invade  the  lymphatic  glands. 

The  presence  of  secondary  nodules  on  the  peritoneum,  omentum,  or  intestine 
is  not  to  be  taken  as  indicating  hopeless  malignancy.  Thomlin''  has  recorded 
cases  in  one  of  which  there  were  vegetations  all  over  the  peritoneum,  and  yet 
at  the  end  of  four  years  the  patient  was  apparently  well  and  cured  ;  while  in 
another  case,  having  to  leave  a  tumour  the  size  of  a  hazel  nut  in  the  pouch  of 
Douglas,  he  was  able  to  assert  three  and  a  half  years  later  that  this  mass  had 
not  increased  in  size.  Pozzi''  says  that  he  has  himself  observed  that  vegetations 
present  on  the  intestines  at  the  first  operation  were  absent  at  a  second  operation. 


382  "  INDEX     OF     PROGNOSIS 

The  presence  of  ascites,  although  obviously  a  grave  complication,  is  not  to 
be  regarded  as  hopeless,  as  numerous  observations  have  been  made  in  which 
the  ascites  was  not  necessarily  fatal.  The  gelatinous  fluid  often  encountered 
in  some  cases  in  this  group  must  be  taken  as  grave,  but  is  indicative  of  the  semi- 
malignant  character.  The  ordinary  rules  as  to  recurrence  in  malignant  growths 
scarcely  apply  to  the  cases  belonging  to  this  group.  Thus,  Pozzi^  operated  on 
a  young  girl  with  enormous  ascites,  and  removed  double  papillomatous  ovarian 
cysts  ;  after  twenty  years  the  growth  took  on  malignant  characters,  and  the 
patient  did  not  survive  the  second  operation  more  than  eighteen  months.  Such 
an  observation,  although  extreme,  is  typical  of  many  cases,  and  leads  to  the 
conclusion  that  in  some  instances  the  growths  take  on  a  more  malignant  nature. 

The  clinical  characters  of  the  more  malignant  tumours  in  this  group  are — 
rapid  and  sudden  enlargement,  rapid  loss  of  weight  with  cachexia,  extensive 
fixation  to  neighbouring  viscera  and  structures,  considerable  oedema  of  the 
limbs  and  abdominal  wall  when  the  volume  of  the  tumour  and  the  amount  of 
ascites  is  taken  into  consideration,  and,  finally,  the  presence  of  pleurisy. 

The  operative  results  in  these  cases  are  not  good.  In  Mrs.  Scharlieb's^  series, 
the  immediate  mortality — that  is,  within  a  month  of  operation — was  about 
15  per  cent,  and  at  least  50  per  cent  were  known  to  have  died  within  three  years. 
There  seems  to  be  no  doubt  that  many  cases  in  this  group,  if  caught  early  before 
dissemination  has  occurred,  are  comparatively  successful  :  when  ascites  and 
secondary  vegetations  are  observed,  it  is  still  advisable  to  remove  both  ovaries 
if  possible,  as  although  the  condition  is  ultimately  almost  certainly  fatal,  yet 
in  some  cases  life  is  prolonged  for  years.  Many  cases  will  require  tapping  from 
time  to  time,  in  order  to  relieve  the  intra-abdominal  tension.  This  simple 
operation  has  been  performed  a  considerable  number  of  times — over  a  period  of 
years  in  some  cases. 

3.  The  Malignant. — The  third  group  includes  malignant  tumours,  whether 
cystic  or  solid.  In  these  cases  the  outlook  is  not  promising.  If  at  the  time 
of  operation  there  is  no  evidence  of  secondary  spread — as  shown  by  vegetations 
on  the  peritoneum,  and  the  presence  of  free  fluid — the  prognosis  is  generally 
regarded  as  better  ;  but  it  is  surprising  how  frequently  such  cases  return  with 
metastases  within  the  year  ;  the  original  diagnosis  was  that  of  an  endothelioma 
or  cystadenoma,  but  in  the  light  of  subsequent  history  it  has  often  to  be  changed 
to  one  of  adenocarcinoma. 

Kachel®  reports  that,  of  all  malignant  ovarian  tumours  upon  which  operation 
is  performed,  only  20  per  cent  are  alive  after  two  years,  and  that  a  considerable 
proportion  of  these  cases  have  extensive  recurrences  of  growth. 

Secondary  Changes. — -Axial  rotation  occurs  in  about  2  per  cent  of  cases  of 
ovarian  cysts,  but  generally  is  much  more  common  in  dermoid  tumours  and 
in  cysts  of  medium  size  and  ovoid  form.  The  operative  results  are  uniformly 
good,  provided  infection  and  necrosis  have  not  occurred. 

Infection  most  commonly  occurs  following  an  axial  rotation.  Provided  the 
case  is  seen  before  extensive  peritonitis  has  occurred,  the  results  are  good,  if 
drainage  is  employed  for  a  few  days  in  all  cases  showing  any  rise  of  temperature. 

Later  results  following  mild  infection  of  the  ovarian  tumour  are  seen  in  dense 
peritoneal  adhesions,  rendering  operation  tedious  and  difficult,  and  greatly 
increasing  the  risk. 

Rupture  was  found  by  Spencer  Wells,  in  a  series  of  1000  cases,  to  take  place 
in  2-4  per  cent,  but  this  figure  appears  abnormally  high.  In  the  majority  of 
cases,  rupture  is  caused  by  rough  examination,  occurs  in  broad-ligament  cysts, 
and  is  attended  by  no  ill  effects.  In  a  few  cases,  however,  papillary  cysts  and 
dermoids  rupture,  causing  dissemination  of  vegetations  or  dermoid  structures. 


PANCREATIC     CYSTS  383 


Ovarian  Tumours  and  Irradiation. — Ovarian  tumours  have  been  treated  by 
X  rays  on  the  assumption  that  iibroids  were  under  treatment,  with  the  result 
that  shrinkage  has  been  described  in  one  or  two  instances,  but  no  record  of 
complete  disappearance  exists.  Kelly  and  Burnam''  record  a  case  of  an  ovarian 
cyst  which,  one  year  after  60  mgrams  of  radium  had  been  applied  for  forty- 
seven  hours,  showed  a  reduction  in  volume  from  8  to  li  inches  in  diameter. 

Ovarian  Tumours  and  Pregnancy. — The  questions  of  operative  interference 
and  the  result  to  be  expected  therefrom  have  special  importance  when  pregnancy 
is  complicated  by  the  presence  of  an  ovarian  swelling.  The  inclination  both  of 
the  medical  attendant  and  of  the  patient  is  to  postpone  any  operative  inter- 
ference; but  the  following  figures  taken  from  a  statistical  article  by  Barrett, ^ 
point  unmistakably  to  the  conclusion  that  the  operative  line  of  treatment  is 
much  the  better  course.  He  gives  the  results  in  114  cases.  Of  these,  76 
were  operated  upon  before  term  :  the  maternal  mortality  is  given  as  1-3  per 
cent,  and  abortion  or  premature  delivery  occurred  in  12  per  cent;  in  8  cases 
double  ovariotomy  was  performed,  and  in  six  of  these  cases,  pregnancy  con- 
tinued to  term.  The  other  38  cases  were  treated  expectantly  and  were  not 
operated  upon  before  term  :  the  maternal  mortality  was  18-4  per  cent  ;  of  the 
total  38  cases,  7  escaped  operation,  but  4  of  these  died,  and  the  remaining  3 
still  have  their  cysts. 

Prognosis  of  Ovarian  Cysts  apart  from  Operation. — In  the  absence  of  operative 
treatment,  the  question  of  the  prognosis  is  more  difficult.  It  is  necessary  to 
refer  to  older  writers,  such  as  Spencer  Wells*,  who  had  occasion  to  see  numerous 
patients  who  refused  operation.  He  asserted  that  when  the  C3'^st  had  attained 
such  a  volume  that  the  general  health  was  affected,  the  duration  of  life  would 
not  exceed  two  years,  and  that  these  two  years  were  full  of  misery,  pain,  and 
despondency. 

On  the  other  hand,  T.  P.  Franck  records  a  case  of  a  cyst  known  to  exist  at 
the  age  of  13,  and  still  present  at  88  years  of  age.  Also  cysts  have  been  known 
to  exist  for  twenty -five  and  even  fifty  years,  but  were  generally  of  dermoid  nature. 

References. — ^Proc.  Roy.  Soc.  Med.  (Obst.  and  Gyn.  Sect.),  1910,  i,  97  ;  ^Ibid.  85  et 
seq.  ;  ^Ibid.  96  ;  *Med.  Times,  1881,  i,  213  and  275  ;  '"Traite  de  Gyn.  ii,  933  ;  ^Centr.  f. 
Gyn.  1907,  li,  1603  ;  ''Jour.  Amer.  Med.  Assoc.  1914,  ii,  622  ;  ^Surg.  Gyn.  and  Obst.  1913, 
Jan.;   ^Ovarian  and  Uterine  Tumours,  1882.  Bryden  Glendining. 

FACET'S  DISEASE. — [See  Osteitis  Deformans.) 

PANCREATIC  CYSTS. — Cysts  of  the  pancreas,  excluding  hydatids  and  blood 
cj^sts,  are  usually  due  to  pressure  upon  the  pancreatic  duct,  either  by  chronic 
inflammation  of  the  head  of  the  gland,  or  scarring  after  an  injury.  This  being  so, 
they  almost  invariably  show  a  steady  increase  in  size  which  necessitates  inter- 
ference, though  they  may  not  at  the  time  be  causing  any  great  inconvenience. 
The  usual  procedure  is  to  open  the  cyst,  perhaps  apply  carbolic  acid  to  its  interior, 
plug  it  with  gauze,  and  drain.  To  attempt  to  dissect  it  out  is  ordinarily  too 
dangerous  to  be  worth  the  trouble. 

The  simple  operation  for  drainage  is  not  very  serious.  Of  160  cases  in  the 
literature  collected  by  Mayo  Robson,  20  died  and  140  i^ecovered,  though  i 
died  later  of  diabetes.  Of  138  cases  treated  by  incision  and  drainage,  16  died 
of  22  treated  by  partial  or  complete  excision,  4  died.  Mayo  Robson  himsel 
had  II  patients,  of  whom  10  recovered.  There  is,  however,  a  good  deal  of 
trouble  occasionally  from  persistence  of  the  sinus,  and  the  discharge  may  contain 
active  trypsin  which  leads  to  self-digestion  and  a  raw  painful  condition  of  the 
skin  about  the  orifice  of  the  drain.  On  the  other  hand,  if  the  sinus  closes,  in  a 
few  cases  the  cyst  has  reformed.  a.  Rendle  Short. 


384  INDEX     OF     PROGNOSIS 


PANCREATITIS. — We  shall  have  to  consider,  (1)  the  prognosis  of  Acute 
pancreatitis,  including  the  suppurative,  haemorrhagic,  and  gangrenous  varieties  ; 
(2)  Abscess  of  the  pancreas;    and  (3)  Chronic  pancreatitis. 

I.  Acute  Pancreatitis. — B}-  this  we  mean  an  acute  attack  of  \'iolent  pain  in  the 
upper  abdomen,  \\ith  some  fever  and  vomiting  and  it  may  be  diarrhoea,  which 
is  of  such  severity  that  an  explorator\-  operation  is  performed  and  reveals 
extensive  areas  of  fat  necrosis,  and  a  swollen,  inflamed,  suppurating,  haemorrhagic, 
or  gangrenous  pancreas.  It  is  almost  impossible  to  make  a  diagnosis  during 
life  with  any  certainty-  apart  from  the  operation-findings.  It  is  therefore  not 
feasible  to  give  any  account  of  the  prognosis  in  non-operated  cases. 

Although  very  grave,  the  condition  is  by  no  means  hopeless.  Thus  Moynihan 
records  7  recoveries  out  of  11  operations.  At  St.  Thomas's  Hospital,  1907-1911, 
there  were  16  cases  \^'ith  7  recoveries  and  9  deaths  ;  at  the  ^Middlesex  Hospital 
8  cases  -with  2  recoveries  and  6  deaths.  On  the  other  hand,  at  three  Bristol 
hospitals,  of  7  cases  all  died,  and  Blaxland  and  Claridge  have  reported  a  series 
of  7  cases,  all  fatal,  at  Norwich.  Korte  finds  in  the  hterature  103  cases  oper- 
ated on  by  fifteen  surgeons  ;  41  recovered  and  62  died.  In  his  own  clnic,  34 
patients  were  treated  by  drainage  of  the  pancreas  ;  of  these,  18  were  cured  and 
16  died.     The  death-rate  is  therefore  probably  about  60  per  cent. 

Death-rate  after  Operation  for  Acute  Pancreatitis. 


Movrdhan 

11 

j 

4 

St.  Thomas's  Hospital      - 

16 

1 

'J 

Middlesex  Hospital 

8 

0 

6 

Bristol    -         -         -          - 

7 

0 

7 

Norwich  -         -         -          - 

7 

0 

1 

Korte  (literature)    - 

103 

41 

1        62 

Korte  (personal) 

34 

18 

1        16 

The  prognosis  varies  with  the  following  conditions  : — 

a.  The  Time  of  Operation. — Thus  Korte  relates  :  Operation  in  first  week, 
12  cases,  8  cured,  4  died  ;  in  second  week,  4  cases,  3  cured,  i  died  ;  operation  in 
3rd  and  4th  weeks,  14  cases,  7  cured,  7  died  ;  operation  later,  all  died.  It 
would  appear,  however,  that  Korte's  series  must  include  a  number  of  mild  cases, 
because  in  Enghsh  practice  the  patient  is  frequently  dead  in  a  week,'  whether 
operated  on  or  not. 

b.  The  Nature  of  the  Operative  Interference. — Mikulicz  quotes  from  a  series 
of  cases  in  the  literature,  where  on  36  occasions  the  pancreas  was  actively  attacked 
(by  blunt  puncture,  etc.)  and  drained,  25  recovering  and  11  dj-ing  ;  in  41  in- 
stances it  was  left  alone,  and  only  4  recovered.  Too  much  importance  must  not 
be  attached  to  these  figures,  because  it  is  probable  that  the  first  group  contains 
less  acute  cases  where  a  definite  abscess  was  found,  and  that  the  latter  group 
would  include  the  gangrenous  and  haemorrhagic  cases  where  there  is  little  to  be 
done  except  put  a  drain  down  to  the  pancreas.  In  Korte's  series,  7  cases  were 
drained  posteriorly  ;    of  these,  5  died. 

c.  The  Operation  Findings. — The  gangrenous  and  hjemorrhagic  cases  are  very 
grave  indeed,  and  seldom  recover  (2  out  of  13  in  Korte's  clinic). 

When  there  was  acute  pancreatitis  without  necrosis  or  pus,  Korte  saved  11 
out  of  14. 

It  is  difficult  to  mention  a  time  of  average  survival,  because  the  patients  differ 
so.     In  many  cases,  they  are  ill  for  less  than  a  week  before  death  terminates  their 


PARALYSIS    AGITANS  385 

sufferings.  Others  drag  on  for  a  month  or  more  ;  they  are  very  liable  to  suffer 
from  self-digestion  of  the  wound,  subphrenic  abscess,  or  pneumonia.  Korte 
had  7  cases  of  severe  post-operative  haemorrhage,  all  but  i  proving  fatal. 

The  writer  has  published  a  case  of  acute  pancreatitis  of  the  accessory  pancreas 
in  the  wall  of  the  jejunum,  which  proved  fatal  in  spite  of  operation. 

2.  Abscess  of  the  Pancreas. — Although  grave,  the  outlook  in  this  group  is  by 
no  means  so  serious  as  in  the  acute  class  just  discussed.  Abscess  of  the  pancreas 
is  generally  the  late  result  of  a  relatively  mild  attack  of  acute  suppurative 
pancreatitis.  Korte  had  7  cases  with  5  recoveries.  Villar  has  abstracted  from 
the  literature  53  cases  of  abscess  of  the  pancreas,  whereof  33  recovered  and  20 
died.  Some  of  those  who  recovered  from  their  immediate  trouble  were  b^'  no 
means  perfectly  cured,  but  eventually  developed  symptoms  of  diabetes,  phthisis, 
or  extreme  wasting. 

3.  Chronic  Pancreatitis. — We  include  here  those  cases  in  which  there  is  chronic 
jaundice  and  perhaps  also  pain,  the  diagnosis  from  gall-stones  on  the  one  hand 
and  cancer  of  pancreas  on  the  other  being  difficult  if  not  impossible.  We  do  not, 
in  this  section,  include  those  cases  in  which  the  classical  symptoms  of  diabetes 
supervene,  but  there  is  always  the  possibility  to  be  borne  in  mind,  in  giving  a 
prognosis,  that  this  disease  may  eventually  declare  its  presence  when  there  is 
known  to  be  cirrhosis  of  the  pancreas  already  present. 

It  is  not  probable  that  chronic  pancreatitis  will  get  well,  apart  from  operation, 
when  it  has  advanced  so  far  as  to  produce  persistent  jaundice.  Two  methods  of 
treatment  are  possible,  cholecystenterostomy  and  drainage  of  the  gall-bladder. 
The  operation  mortality  is  given  by  Mayo  Robson  as  8  deaths  in  113  cases  from 
the  literature,  so  that  the  true  mortality  may  be  about  10  per  cent — higher,  no 
doubt,  after  cholecystenterostomy  than  after  simple  drainage.  Neither  operation 
can  be  relied  upon  to  give  first-class  results  ;  the  fistula  may  fail  to  close,  and  if 
the  gall-bladder  and  duodenum  have  been  short-circuited,  sepsis  may  invade 
the  bile-passages  from  the  bowel.  Accurate  figures  are  lacking,  but  probably 
the  majority  of  the  patients  are  cured  by  a  cholecystenterostomy. 

References. — Mikulicz,  Ann.  Surg.  1903,  ii,  i  ;  Sampson  Handley,  Archiv.  Middlesex 
Hosp.  1912,  Feb.  20  ;  Korte,  Ann.  Surg.  1912,  Iv,  23.  ^.  Rendle  Short. 

PAPILLOMA  OF  THE  LARYNX.— (See  Larynx.  Papilloma  of.) 

PARALYSIS  AGITANS. — This  is  a  progressive,  but  not  a  fatal,  malady.  Be- 
ginning unilaterally  in  most  cases,  it  may  remain  confined  to  the  face  and  limbs, 
of  one  side  for  years  ;  but  sooner  or  later  the  other  side  also  becomes  affected 
with  the  characteristic  rigidity  and  tremor.  Worry,  excitement,  business  anxiety, 
and  strenuous  mental  exertion  all  aggravate  its  symptoms.  The  rigid,  mask- 
like face,  with  its  expression  of  unutterable  sadness,  not  infrequently  disguises  a 
cheerful,  and  even  a  humorous,  frame  of  mind ;  although,  in  other  cases,  the 
patient  becomes  depressed  by  the  consciousness  of  the  inveterate  nature  of  his 
malady. 

The  intellectual  faculties,  however,  are  usually  preserved  unimpaired,  even  in 
the  most  advanced  stages  of  the  disease.  By  the  judicious  administration  of 
hyoscine,  we  can  usually  mitigate  not  only  the  rigidity  and  tremor,  but  the 
characteristic  restlessness  which  is  so  trying  to  the  patient.  Purves  Stewart. 

PARALYSIS,  BULBAR.— (.See  Bulbar  Palsy.) 

PARALYSIS,  INFANTILE.— (5ee  Infantile  Paralysis.) 

PARANOIA. — (See  Mental  Diseases.) 

25 


386  INDEX     OF     PROGNOSIS 

PARATYPHOID  FEVER.— There  are  two  varieties  of  this  disease,  the  one 
due  to  the  Bacillus  paratyphosus  {A),  and  the  other  to  the  Bacillus  paratyphosus 
(B).  The  former  is  met  with  in  Asia,  and  especially  India,  and  not  in  Europe  ; 
the  latter,  on  the  other  hand,  occurs  in  Europe  and  is  rare  in  Asia. 

The  fatality  of  paratyphoid  (A)  is  about  2  per  cent ;  of  paratyphoid  {B)  about 
3  per  cent.  The  fatahty  is  therefore  much  lower  than  that  of  typhoid  fever. 
But  paratyphoid  cannot  be  distinguished  from  typhoid  fever  except  by  bacterio- 
logical examination  of  the  blood  and  stools,  or  by  careful  agglutination  tests. 

Death  in  paratyphoid  fever  is  usually  due  to  some  complication  ;  and  the 
complications  are  much  the  same  as  are  met  with  in  typhoid,  though  their 
incidence  in  the  one  disease  is  much  lower  than  in  the  other.  If,  therefore,  any 
complication  arises,  the  prognosis  should  be  based  on  the  same  considerations 
as  apply  in  the  case  of  typhoid  fever.  £.  J4/.  Goodall. 

PELIOSIS  RHEUMATICA.— (5ee  Purpura.) 

PEMPHIGUS  AND  PEMPHIGOID  AFFECTIONS.  —  It  is  important  to 
define  exactly  what  diseases  are  included  under  the  term  pemphigus  before 
endeavouring  to  estimate  the  prognosis.  The  description  '  pemphigus  '  has 
been  applied  to  many  eruptions  characterized  by  the  formation  of  bullae  or 
blisters,  but  the  use  of  the  word  is  now  more  limited.  Recently  the  convenient 
term  '  pemphigoid  '  has  been  coined  to  cover  a  number  of  allied  conditions 
which  will  be  considered  here. 

Pemphigus  Neonatorum  is  a  bullous  variety  of  impetigo  occurring  in  newly -born 
infants.  The  eruption  is  chiefly  on  the  trunk,  and  is  often  associated  with  a 
septic  condition  of  the  umbilicus.  The  mortality  is  about  30  per  cent.  The 
cause  of  death  is  generally  septicaemia  or  pyaemia,  the  infection  becoming 
generahzed  through  the  umbilical  stunip.  Provided  the  lesions  are  confined  to 
the  skin,  and  that  they  are  properly  dressed  by  antiseptic  ointments,  the  outlook 
is  not  unfavourable. 

Pemphigus  Contagiosus  is  the  name  given  to  a  bullous  impetigo  which  is  most 
commonly  seen  in  the  tropics,  but  is  occasionally  met  with  in  this  country.  The 
eruption  consists  of  large  blebs  filled  with  a  serous  fluid  at  first,  but  subsequently 
the  contents  may  become  purulent.  To  this  eruption  the  name  pemphigus  is 
often  given,  and  many  of  the  so-called  mild  cases  of  the  disease  are  of  this  type. 
The  eruption  usually  yields  rapidly  to  antiseptic  treatment. 

Epidermolysis  Bullosa  (so-called  Hereditary  Traumatic  Pemphigus)  is  a  rare 
affection,  characterized  by  the  formation  of  blebs  containing  serum  or  blood, 
caused  by  slight  friction  or  pressure  which,  in  the  normal  subject,  would  be 
unattended  with  any  reaction  whatever.  It  varies  very  much  in  its  severity, 
and  various  degrees  are  often  seen  in  several  members  of  the  same  family  and 
through  several  generations.  If  severe,  it  may  incapacitate  the  sufferer  from 
doing  ordinary  labour  throughout  life.  In  the  less  severe  cases,  it  is  a  constant 
source  of  annoyance  and  a  hindrance  to  work.  Moreover,  the  abraded  surfaces 
are  Uable  to  infection.  Though  the  disease  must  be  looked  upon  as  incurable, 
there  are  cases  in  which  the  development  of  the  blebs  becomes  less  marked  with 
the  approach  of  puberty. 

Dermatitis  Herpetiformis. — This  affection  is  one  of  the  most  troublesome  m 
the  domain  of  dermatology.  It  is  characterized  by  the  development  of  a  poly- 
morphic eruption,  consisting  of  erythematous  areas  Avith  groups  of  herpetiform 
vesicles  or  bullae  of  variable  size.  The  eruption  is  attended  with  great  irritation, 
and  sometimes  with  pain.  It  tends  to  develop  in  earl}^  life,  and  may  persist  for 
many  years.     The  attacks  occur  at  intervals,  and  vary  greatly  in  their  severity. 


PENIS,     CARCINOMA      OF  387 

In  some  cases  the  periods  of  intermission  are  very  short,  so  that  the  sufferer  is 
rarely  free  from  the  eruption  ;  in  others,  there  are  long  intervals  between  the 
attacks.  An  attack  can  usually  be  controlled  by  arsenic,  pushed  to  the  capacity 
of  the  patient,  and  by  ointments  containing  sulphur.  In  some  instances  the 
patient  is  able  to  carry  on  his  avocations  owing  to  the  limited  area  affected  ; 
in  others  an  almost  complete  incapacity  is  produced.  We  are  ignorant  of  the 
cause  of  the  affection,  and  are,  therefore,  unable  to  do  more  than  temporarily 
relieve  the  condition. 

Hydroa  Gravidarum  or  Hydroa  Gestationis  is  dermatitis  herpetiformis  occurring 
in  pregnant  women.  It  commonly  appears  between  the  third  and  sixth  month, 
and  often  recurs  with  successive  pregnancies  ;  as  a  rule,  the  severity  of  the 
disease  increases  with  each  succeeding  attack.  In  many  cases  the  eruption 
clears  up  soon  after  the  delivery  of  the  child  ;  but  in  some  instances  the  disease 
may  start  after  parturition.  It  is  rare  to  find  the  condition  so  severe  as  to 
determine  the  pregnancy,  and  recovery  is  the  rule. 

Pemphigus  Acutus. — This  is  a  rare  affection  occurring  in  butchers  and  others 
who  handle  dead  carcases.  It  is  believed  to  be  due  to  a  diplococcus,  which  has 
been  isolated  by  Bulloch  and  others.  The  prognosis  is  extremely  grave.  The 
symptoms  are  those  of  a  grave  septicaemia,  and  death  occurs  in  75  per  cent  of  the 
cases,  in  from  one  to  three  weeks  after  the  onset  of  the  disease.  In  the  minority 
of  the  cases,  convalescence  begins  in  from  three  to  four  weeks. 

Pemphigus  Chronicus. — This  disease,  which  is  somewhat  rare,  is  of  grave 
prognosis.  Of  30  cases  admitted  with  this  diagnosis  into  the  wards  of  the  London 
Hospital,  19  died,  but  this  does  not  represent  the  entire  mortality,  because 
several  cases  running  a  very  chronic  course  were  removed  to  the  infirmary  and 
died  there.  It  is  exceedingly  difficult  to  state  at  the  onset  what  course  the 
affection  is  likely  to  run,  for  many  cases  begin  with  a  limited  eruption  which 
gradually  extends  in  spite  of  treatment.  As  a  rule,  the  younger  subjects  are 
most  likely  to  recover.  The  fatal  issue  usually  occurs  in  from  three  to  eighteen 
months,  but  in  some  cases  a  longer  course  is  seen,  the  disease  passing  on  to 
pemphigus  foliaceus. 

Pemphigus  Foliaceus. — This  variety  of  pemphigus  is  characterized  by  the 
formation  of  flaccid  bullae,  followed  by  a  condition  of  general  exfoliation  of  the 
skin.  It  may  be  primary,  or  the  sequel  of  the  chronic  form  of  pemphigus,  or 
rarely  of  dermatitis  herpetiformis. 

The  course  is  chronic,  and  the  affection  may  persist,  with  exacerbations  and 
remissions,  for  two  or  three  years  or  longer.  A  fatal  issue  is  brought  about  by 
gradual  asthenia,  diarrhoea,  or  some  intercurrent  disease. 

Pemphigus  Vegetans. — This  is  an  exceedingly  rare  disease,  characterized  by 
the  formation  of  bullae  in  the  base  of  which  vegetations  rapidly  develop.  The 
fatal  issue  usually  occurs  in  from  two  to  six  months.  Though  nearly  always 
fatal,  a  few  cases  occur  in  which  the  eruption  is  limited  to  the  limbs  and  trunk, 
and  runs  a  benign  course.  j.  //.  Sequeira. 

PENIS,  CARCINOMA  OF. — Prognosis  always  depends  upon  accurate  diagnosi.', 
and  therefore  it  will  be  necessary,  before  giving  an  opinion  as  to  the  outlool, 
to  make  certain  that  the  condition  is  not  a  tertiary  syphilitic  ulcer,  primary 
chancre,  or  mass  of  hard  warts,  all  of  which  are,  of  course,  curable  conditions. 

Epithelioma  of  the  penis  is  not  a  particularly  malignant  variety  of  cancer. 
Apart  from  operation,  it  always  leads  to  a  fatal  termination  in  the  course  of  one  to 
three  years. 

Various  methods  of  operative  treatment  are  in  use,  such  as  :  Amputation  of 
the  penis  ;  extirpation  of  the  penis  (Pearce  Gould's  method)  ;   one  of  the  above 


INDEX     OF     PROGNOSIS 


with  bilateral  removal  of  inguinal  glands,  either  at  the  same  time  or  subse- 
quently. 

The  disease  is  uncommon,  and  reliable  statistics  are  not  easy  to  obtain.  Mere 
amputation  of  the  penis,  except  in  a  broken-down  subject,  is  a  trifling  operation. 
At  St.  Bartholomew's  Hospital,  prior  to  1900,  there  was  i  death  in  53  cases. 
The  mortality  of  Gould's  operation  at  that  time  was  said  to  be  6  per  cent. 
Clearance  of  the  groin  glands  would,  no  doubt,  add  to  the  risk  to  some  extent, 
but  the  immediate  danger  to  life  depends  far  more  on  the  general  health  of  the 
individual  than  on  the  exact  nature  of  the  operation. 

The  end-results  were  worked  out  by  Butlin^  in  a  series  of  65  cases  treated, 
prior  to  1900,  by  simple  amputation  of  the  penis,  usually  without  clearance  of 
the  inguinal  glands.  Of  65  cases  followed  three  years,  23  were  still  free  from 
recurrence,  or  35  per  cent.  There  were  no  difficulties  with  micturition, 
and  coitus  was  still  possible  for  some  of  them.  The  principal  factors  in  prognosis 
are  the  rate  of  growth  up  to  the  time  seen  and,  especially,  whether  the  groin 
glands  are  palpably  enlarged  ;  if  they  are,  the  outlook  is  much  more  serious  than 
in  cases  where  they  cannot  be  felt. 

Of  9  recurrent  cases,  in  3  the  growth  returned  in  the  penis,  and  in  6  in  the  groin 
glands  only.  This  is,  of  course,  a  strong  argument  for  clearance  of  the  inguinal 
region.  It  also  demonstrates  that  total  extirpation  of  the  penis  by  Gould's 
method  need  only  be  adopted  for  extensive  growths,  because  there  is  no  great 
tendency  to  spread  back  in  the  corpora  cavernosa.  It  would  no  doubt  be  wise, 
and  it  is  quite  possible,  to  remove  the  lymphatics  of  the  deep  fascial  plane  in  a 
continuous  sheet,  from  the  growth  to  the  inguinal  glands,  by  a  dorsal  incision 
along  the  penis. 

Even  if  the  patient  is  not  permanently  cured,  amputation  of  the  penis  is 
nearly  always  a  great  relief  to  liim. 

Reference. —  ^Butlin,    Operative   Surgery    of    Malignant   Disease,   2nd  ed. 

A.  Rendle  Short. 

PERICARDITIS. — {See  also  Rheumatic  Peri-,  Myo-  and  Endocarditis.) 
Nowhere  is  a  knowledge  of  etiology  and  pathology  more  essential  to  clinical 
accuracy  than  in  pericarditis.  It  is  quite  futile  to  attempt  a  forecast  of  the 
probabilities  in  a  case  of  pericarditis  without  knowing  how  it  began.  There 
are  two  reasons  for  this.  First,  the  lesions  underlying  or  associated  with  peri- 
cardial inflammation  may  have  far  more  bearing  on  the  course  of  the  case  than 
the  pericarditis  itself.  Second,  inflammation  of  the  pericardium  runs  a  very 
different  course  according  to  the  cause. 

The  commonest  of  all  the  forms  of  pericardial  inflammation  is  that  which 
is  associated  Avith  rheumatic  carditis.  As  this  is  discussed  under  a  separate 
heading  (see  Heart,  Chronic  Valvular  Disease  of),  no  more  need  be  said 
here  than  will  serve  to  bring  it  into  line  with  the  other  types.  First,  it 
is  scarcely  accurate  to  speak  of  rheumatic  pericarditis  as  if  it  were  of  itself 
a  disease.  It  is  never  more  than  one  feature  of  that  which  includes  it — 
namely,  rheumatic  pancarditis.  When  the  rheumatic  infection  attacks  the 
heart,  the  muscle  and  the  mitral  valve  are  always  injured,  the  pericardium 
nearly  always,  and  the  other  valves  sometimes.  When  the  pericardial  inflam- 
mation is  sufficiently  intense,  it  gives  rise  to  an  audible  rub.  This  is  so  striking 
a  feature  of  the  case  that  it  is  labelled  '  pericarditis,'  and  the  fundamental 
fact  that  the  whole  heart,  and  not  the  pericardium  only,  is  damaged,  is  lost 
sight  of.  Second,  the  fact  that  there  are  signs  of  pericarditis  is  nevertheless 
of  considerable  prognostic  importance,  for  it  is  a  proof  that  the  dose  of  infective 
agent  that  has  been  cast  into  the  heart  by  its  coronary  blood-supply  is  a  large  one. 
The  mortality  of  cases  in  which  a  rub  is  heard  is  much  higher  than  in  cases  of 


PERICARDITIS  389 


rheumatic  carditis  without  friction  (20  per  cent,  as  compared  with  a  mortality 
certainly  under  10  per  cent  even  if  only  severe  cases  be  included).  Third,  the 
permanent  disabling  of  the  heart  is  greater  in  cases  of  rheumatic  carditis  with 
implication  of  the  pericardium  than  it  is  in  those  that  show  no  signs  of  pericarditis, 
for  a  certain  amount  of  adhesion  is  an  inevitable  result  of  rheumatic  pericarditis. 
The  extent  to  which  these  adhesions  inflict  real  disability  on  the  heart  is  doubtful  ; 
some  allusion  to  this  matter  will  be  made  below.  Finally  (and  this  also  will  be 
discussed  below),  effusion  into  the  pericardial  sac  is  a  very  rare  complication 
of  rheumatic  carditis.  Most  of  the  cases  in  which  this  used  to  be  diagnosed 
were  in  reality  cases  of  acute  dilatation  due  to  myocarditis.  The  whole  import 
of  rheumatic  pericarditis,  therefore,  is  that  it  is  a  sign  that  the  attack  of  carditis 
of  which  it  is  one  feature  is  a  severe  one.  In  general,  the  more  definite  and 
intense  the  signs  of  pericarditis,  the  worse  is  the  outlook  ;  but  the  state  of  the 
myocardium  is  far  more  important  than  that  of  the  pericardium,  and  it  is  in  this 
direction  that  one  should  look  for  guidance  in  prognosis. 

A  second  type  of  pericarditis  is  that  provoked  by  the  pneumococcus .  This 
may  occur  as  a  complication  of  lobar  pneumonia  in  adults,  or  in  small  children 
in  connection  with  empyema.  In  the  latter  group  it  is  difficult  to  detect  and 
equally  difficult  to  treat  ;  the  results  are  therefore  very  bad.  The  examples 
of  accurate  diagnosis  and  early  operation  are  very  few  ;  whereas  suppura- 
tive pericarditis  is  a  fairly  common  complication  of  pneumococcal  empyema  in 
infants  and  young  children. 

Of  the  102  cases  complicating  lobar  pneumonia  collected  by  various  writers, 
70,  or  68  per  cent,  ended  fatally.  This  of  course  excludes  cases  in  which  the 
diagnosis  was  only  made  post  mortem.  In  both  types  of  case  it  is  possible  that 
operation  facilitated  by  early  diagnosis  might  not  have  saved  raany  lives  ;  for 
when  pericarditis  occurs  in  small  children,  the  patient  is  nearly  always  very  ill 
as  a  result  of  an  empyema,  of  which  the  pericardial  lesion  is  only  a  complication  : 
and  the  adults  who  show  signs  of  pericarditis  with  their  pneumonia  are  often 
of  the  type  that  resists  the  original  disease  badly.  Moreover,  the  pneumococcal 
effusions  are  seldom  large,  so  that  even  if  operation  were  more  often  possible 
it  might  not  add  a  great  deal  to  the  patient's  chance  of  recovery.  Still,  the 
fact  remains  that  if  there  is  an  effusion  of  any  bulk,  nothing  but  operation 
can  save  the  patient's  life.     The  choice  of  operation  will  be  considered  below. 

Cases  of  tuberculous  pericarditis  do  better  so  far  as  the  immediate  results  of 
operative  procedure  are  concerned.  It  is  true  that  of  42  cases  so  treated,  only 
II  are  regarded  by  those  who  report  them  as  being  cured  ;  but  this  is  because 
in  many  instances  temporary  amelioration  was  followed  by  aggravation  of  the 
lesions  in  other  organs.  Tuberculosis  of  the  pericardium  is  nearly  always  part 
of  a  more  general  infection,  and  it  is  on  this  fact  that  the  prognosis  largely  turns. 
There  are  two  kinds  of  cases,  the  chronic  adhesive  and  the  acute  exudative  ; 
the  former  complicates  the  more  chronic  form  of  pulmonary  tuberculosis,  the 
latter  arises  as  the  result  of  generalized  infection.  The  patient's  chances  of 
survival  turn  in  part  only  on  the  course  of  his  pericardial  infection,  if  there  be 
tuberculosis  of  other  tissues.  If  it  be  merely  one  event  in  a  generalized  miliary 
tuberculosis,  it  is  obvious  that  the  only  prognostic  importance  of  signs  of  tubercu- 
losis of  the  pericardium  is  that  they  reveal  something  of  the  intensity  of  the 
infection,  and  by  that  much  add  to  the  gravity  of  the  prospect. 

Much  the  same  is  true  of  the  pericarditis  which  may  complicate  the  various 
forms  of  septiccBmia  and  pycemia.  In  many  cases,  no  doubt,  it  is  only  at  the 
post-mortem  that  these  lesions  are  found.  This  fact  was  borne  in  upon  the 
writer  some  years  ago,  in  the  course  of  an  investigation  into  the  cardiac  lesions 
of  pyaemia.     The  number  of  cases  of  pyaemia  recorded  in  the  autopsy  books  of 


390  INDEX     OF     PROGNOSIS 

the  old  pre-antiseptic  days  of  surgery  was  in  itself  a  revelation  ;  and  in  a  very 
large  percentage  of  these  the  pericardium,  contained  pus.  Nowadays  this  type 
of  pericarditis  is  happily  less  familiar,  but  we  encounter  it  sometimes  as  a  feature 
of  puerperal  septicaemia,  acute  osteomyelitis,  and  the  hke.  When  it  occurs  under 
these  circumstances,  pericarditis  is  of  necessity  a  grave  factor  in  an  already 
unpromising  situation,  since  it  furnishes  evidence  that  the  circulating  blood  is 
saturated  with  micro-organisms.  But  this  does  not  carry  with  it  an  immediate 
sentence  of  death,  for  the  literature  contains  several  instances  of  recovery  after 
surgical  treatment  of  pyopericardium  due  to  this  type  of  infection.  It  is  true 
that  in  most  of  these  cases  death  has  not  been  long  delayed.  Some  other  lesion 
of  a  vital  organ,  arising  from  the  same  infective  process,  kills  the  patient,  even 
though  the  pericardiuni  has  been  successfully  drained. 

Pericarditis  is  an  occasional  complication  of  typhoid  fever.  It  is  not  invariably 
fatal ;   two  of  the  three  cases  observed  by  Thayer. recovered. 

The  same  is  true  of  pericardial  lesions  provoked  by  gonococcal  infection  ;  in 
the  case  recorded  by  Robin  and  Fiessinger  recovery  followed  paracentesis. 

In  the  pericarditis  of  scarlet  fever  the  prognosis  depends  on  the  nature  of  the 
organism  provoking  it.  If  the  pericardial  inflammation  be  but  one  incident 
in  the  course  of  a  severe  septic  scarlatina,  its  importance  is  that  it  adds  to  the 
gravity  of  the  prognosis.  If  it  arise  during  or  after  convalescence,  it  is  most 
probably  rheumatic,  and  the  prognosis  is  that  of  acute  rheumatic  carditis. 

Four  other  forms  of  pericarditis  remain  to  be  considered.  The  so-called 
terminal  cases,  due  to  streptococcal  and  staphylococcal  infection,  and  compli- 
cating chronic  diseases,  especially  renal  disease,  are  not  always  fatal.  It  is 
impossible  to  set  this  statement  on  a  statistical  basis,  because  there  are  two  facts 
which  vitiate  any  calculations — the  difficulty  of  discerning  between  true  peri- 
carditis and  mere  hydropericardium,  and  the  very  small  percentage  of  pericardial 
lesions  of  this  type  which  are  diagnosed  during  life  In  general  it  may  be  said 
that  the  appearance  of  pericarditis  in  any  chronic  disease  such  as  diabetes, 
Bright's  disease,  or  cancer,  adds  substantially  to  the  immediate  risks,  the  chance 
of  survival  depending  almost  entirely  on  the  general  condition  of  the  patient  at 
the  onset  of  the  pericarditis. 

In  traumatic  pericarditis  the  outlook  naturally  depends  on  a  variety  of  factors, 
apart  from  the  state  of  the  pericardium  itself.  Limiting  our  consideration  to 
the  pericardial  lesions  as  far  as  possible,  we  find  that,  if  all  cases  be  included, 
the  mortality  is  about  40  per  cent.  If  only  those  cases  be  counted  in  which  the 
injury  has  failed  to  penetrate  the  chest  wall,  it  seems  that  about  three-quarters 
get  well.  In  the  open  cases  the  occurrence  of  air  in  the  pericardium  is  not 
necessarily  fatal. 

When  the  pericardium  becomes  implicated  in  malignant  disease  arising  within 
the  thorax,  signs  of  pericarditis  may  become  manifest.  In  such,  a  promise  of 
immediacy  is  added  to  an  already  fatal  prognosis.  This  is  particularly  true  of 
perforation  of  the  cancerous  oesophagus  into  the  pericardial. cavity. 

Last  of  all,  there  is  the  pericardial  rub  which,  appearing  suddenly  in  a  case 
of  chronic  myocardial  disease,  furnishes  proof  of  some  gross  lesion  of  the  cardiac 
wall — thrombosis,  embolism,  or  rupture.  This  is  always  a  sign  of  the  utmost 
gravity,  for  even  if  the  patient  be  not  immediately  destroyed,  his  survival  cannot 
be  more  than  brief. 

But  it  is  not  only  as  a  revelation  of  sinister  forces  that  pericarditis  carries  a 
threat  of  death.  The  rapid  collection  of  fluid  within  the  pericardial  sac  may 
kill  the  patient.  There  is  also  the  formation  of  adhesions,  and  their  influence 
on  the  cardiac  efficiency,  to  be  thought  of.  Acute  sero-fibrinous  pericarditis 
cannot  of  itself  kill  the  patient  ;   but  it  does  on  the  one  hand  prove  the  existence 


PERICARDITIS  39i 


of  certain  collateral  dangers,  such  as  rheumatic  myocarditis  ;  while  on  the  other 
hand  it  threatens  more  or  less  directly  to  hamper  and  possibly  overcome  the 
heart  by  leading  to  pericardial  effusion  or  adhesion. 

Effusion  into  the  pericardium,  in  amounts  sufficient  to  endanger  the  life  of  the 
patient,  is  a  very  rare  result  of  rheumatic  infection.  Some  eminent  observers 
declare  that  it  never  amounts  to  enough  to  call  for  paracentesis.  There  are, 
however,  a  number  of  cases  of  the  kind  in  which  it  has  been  thought  necessary 
to  puncture  the  sac.  In  these  the  results  were  roughly  as  follows  :  the  course 
of  the  case  was  not  materially  altered  in  about  50  per  cent ;  in  25  per  cent  there 
was  some  transient  improvement  ;  while  in  the  remaining  25  per  cent 
paracentesis  appeared  to  give  material  and  lasting  relief  from  a  condition  of 
urgent  peril.  The  writer  has  never  seen  a  case  of  rheumatic  pericarditis  in  which 
the  operation  would  have  been  justified,  either  by  the  signs  during  life  or  by  the 
post-mortem  findings.  In  the  series  of  cases  of  effusion  into  the  pericardium 
brought  forward  at  the  Royal  Society  of  Medicine  discussion  in  1910,  there  were 
only  9  rheumatic  cases  in  which  it  had  been  thought  advisable  to  empty  the  sac, 
and  in  only  3  of  these  was  life  prolonged  by  the  proceeding.  Clear  effusions 
are  perhaps  more  characteristic  of  tuberculosis  than  of  any  other  infective 
process,  but  they  are  often  semi-purulent  in  this  disease.  As  has  been  already 
remarked,  the  immediate  outlook  in  those  cases  of  tuberculous  effusion  that  are 
diagnosed  during  life  (about  6  per  cent  of  all  cases)  is  fairly  good  ;  the  choice 
between  paracentesis  and  pericardiotomy  seems  to  depend  on  the  character  of 
the  fluid,  the  former  procedure  sufficing  for  the  clear  cases,  while  the  more 
elaborate  operation  is  called  for  if  the  exudate  be  puriform.  At  any  rate,  the 
results  in  the  published  cases,  in  which  this  rule  seems  to  have  been  roughly 
followed,  work  out  about  equal.  It  should  be  added  that  if  the  exudate  be 
hsemorrhagic,  this  is  no  contra-indication  to  paracentesis,  as  cure  has  followed 
the  operation  is  several  such  cases.  This  is  true  of  pericarditis  due  to  other 
infections  beside  tuberculosis.  The  dangers  of  simple  hydropericardium  are  as  a 
rule  overshadowed  by  the  more  direct  risks  implied  by  the  underlying  lesions, 
and  the  outlook  is  therefore  that  of  the  cause. 

Pyopericardium  is  a  desperately  dangerous  disease,  whatever  the  infection 
that  is  responsible  for  it.  The  risks  are,  first,  those  due  to  such  other  lesions 
as  the  causal  infection  may  have  provoked  ;  second,  those  that  arise  from  the 
fact  that  purulent  pericarditis  is  very  difficult  to  detect  (in  only  6  of  Poynton's 
100  cases  in  children  was  it  diagnosed  during  life)  ;  third,  those  that  are  due  to 
the  risks  of  surgical  treatment,  the  only  form  of  treatment  that  can  hold  out 
any  hope  of  cure  ;  and  finally,  those  that  are  included  within  the  possibility  of 
increase  of  the  effusion  to  the  point  at  which  the  cardiac  movements  become 
fatally  hampered. 

Suppose  the  condition  has  been  detected  in  a  patient  who  is  fit  to  be  operated 
on  ;  what  plan  of  treatment  promises  the  best  results  ?  The  figures  published 
by  various  writers,  and  tabulated  in  Blechmann's  excellent  monograph,  show 
that  mere  paracentesis  has  never  saved  life  ;  that  the  percentage  of  survivals 
after  incision  of  the  pericardial  sac  is  about  46  in  a  total  of  nearly  100  recorded 
cases  ;  that  the  recovery-rate  following  simple  incision  is  28  per  cent ;  after 
pericardiotomy  with  costal  resection,  55  percent;  after  operation  through  the 
epigastric  incision  recommended  by  Ogle,  66  per  cent.  These  figures  demonstrate 
clearly  the  superiority  of  the  methods  in  which  free  drainage  is  secured.  Such 
figures  as  are  available  are  not  very  convincing  as  to  the  advisability  or  otherwise 
of  drainage  in  pericardial  tuberculosis  ;  but  the  general  opinion  of  surgeons  and 
physicians,  expressed  at  recent  discussions,  is  to  the  effect  that  if  incision  be 
practised  at  all,  it  should  be  sewn  up  and  not  left  to  drain. 


392  INDEX    OF     PROGNOSIS 

In  pneumopericardium  the  outlook  is  of  necessity  dependent  to  a  large  extent 
on  the  antecedent  conditions  ;  and  as  it  often  forms  a  late  incident  in  a  morbid 
process  that  would  be  sufficiently  desperate  even  if  there  were  no  irruption  into 
the  pericardium,  it  is  not  to  be  wondered  at  that  the  death-rate  is  high — 28  out 
of  43  cases  (Cowan,  Harrington,  and  Riddell).  The  more  abrupt  the  invasion 
of  the  pericardial  sac,  the  worse  the  prognosis. 

There  remains  to  be  considered  the  vexed  question  of  chronic  adhesive  peri- 
carditis. This  is  met  with  under  several  sets  of  circumstances.  In  the  cardiac 
rheumatism  of  childhood,  some  adhesion  is  very  common  (in  three-quarters 
of  Poynton's  autopsy  cases,  and  nearly  half  of  the  writer's).  In  the  various 
forms  of  chronic  indurative  mediastinopericarditis  the  sac  is  more  or  less 
obhterated.  A  third  rare  group  of  cases  is  that  embraced  within  the  term 
'  polyserositis.'     These  may  be  due  to  tuberculosis  or  to  no  obvious  cause. 

It  would  at  first  sight  appear  to  be  a  simple  matter  to  accept  the  position  that 
adherent  pericardium  is  always  a  serious  condition  ;  but  there  are  two  considera- 
tions that  complicate  the  issue.  In  the  first  place,  all  the  diseases  named  inflict 
other  disabihties  on  the  heart  or  other  vital  organs,  and  it  is  difhcult  to  separate 
these  from  the  direct  effects  of  pericardial  adhesion.  In  the  second  place,  the 
fact  that  the  pericardium  is  adherent  is  by  no  means  always  discoverable 
clinically.  The  rheumatic  type  of  case  is  by  far  the  commonest,  and  here  there 
is,  in  the  writer's  opinion,  no  reliable  sign  of  pericardial  adhesion.  Of  all  the 
phenomena  that  have  been  described  as  pointing  in  this  direction,  there  is  not 
one  that  may  not  be  present  in  the  absence  of  adhesion  ;  and  it  would  seem  that 
all  of  them  are  due  rather  to  the  great  cardiac  enlargement  that  is  so  constant 
a  feature  of  just  those  cases  in  which  post-rheumatic  adhesion  of  the  pericardial 
sac  is  likely  to  occur — in  the  adolescent  or  young  adult  who  has  just  managed 
to  survive  repeated  attacks  of  acute  rheumatic  carditis,  though  with  a  heart 
much  enlarged  and  otherwise  crippled.  Be  this  as  it  may,  the  fact  no  doubt 
remains  that  in  those  cases  of  post-rheumatic  disease  in  which  there  are  adhesions 
not  only  obliterating  the  pericardial  sac  but  also  binding  the  epicardium  to  the 
neighbouring  tissues,  the  heart  carries  on  its  work  far  less  efficiently  than  in  cases 
where  there  are  only  valvular  disabilities  to  be  overcome.  If,  therefore,  the 
clinician  feels  himself  in  a  position  to  diagnose  this  condition  in  a  case  of  post- 
rheumatic heart-disease,  the  prognosis  he  must  form  will  be  much  graver  ; 
patients  in  this  class  of  case  rarely  attain  the  age  of  thirty.  In  the  non-rheumatic 
type  of  case  the  prognosis  is  to  be  reached  along  the  same  lines  ;  if  there  be 
signs  of  adhesion  uniting  both  pericardial  layers  into  one  membrane,  and  that 
again  into  inseparable  fusion  with  the  surrounding  tissues  (and  nobody  claims 
to  be  able  to  diagnose  mere  intrapericardial  adhesions),  then  the  prospect  of 
cardiac  failure,  within  a  few  years  at  the  outside,  is  added  to  such  other  portents 
as  the  disease  in  its  attack  on  other  organs  may  furnish. 

The  main  interest  of  the  question  as  to  the  influence  of  treatment  on  prognosis 
centres  around  the  effect  on  the  patient's  outlook  of  the  operation  described 
by  some  as  cardiolysis,  but  more  accurately  by  others  as  thoracostomy.  Of  30 
cases  of  which  the  writer  has  been  able  to  collect  the  reports,  only  i  died  as  the 
immediate  result  of  the  operation  ;  of  the  remainder,  7  are  described  as  receiving 
little  or  no  benefit,  while  in  the  remaining  22,  various  degrees  of  improvement 
were  observed.  In  reading  these  records,  one  is  struck  by  the  fact  that  the 
disappointments  occurred  principally  in  the  rheumatic  cases,  and  operations 
of  this  kind  are  not  likely  to  be  practised  in  the  future  for  such  cases,  except 
perhaps  as  giving  space  to  an  enlarged  heart.  The  cases  most  likely  to  benefit 
from  this  operation  belong  to  the  polyserositis  group.  Carev  F.  Coomb's. 

PERITONITIS,    PNEUMOCOCCIC. — {See   Pneumococcic  Peritonitis.) 


PERITONITIS,     TUBERCULOUS 


393 


PERITONITIS,  TUBERCULOUS. — It  is  very  difficult  to  appraise  correctly 
the  relative  value  of  medical  and  surgical  treatment  in  this  disease. 

Results  of  Medical  Treatment. — We  \\all  first  collect  the  evidence  as  to  the 
outlook  when  cases  are  treated  by  medical  means  only.  There  is  no  lack  of 
statistics  of  a  sort,  but  many  of  them  are  vitiated  by  ill-arrangement,  inadequate 
details,  or  too  early  reporting.  Thus  Faludi,  by  adding  up  a  mass  of  German 
reports,  quotes  156  cases  treated  without  operation,  of  which  about  a  third 
got  well ;  but  we  do  not  know  for  how  long  a  time  they  were  watched.  The 
writer  has  obtained  details  of  14  cases  treated  in  various  institutions  in  Bristol 
by  fresh  air,  iodoform,  mercurial  ointment,  cod-liver  oil,  etc.  All  of  these  were 
followed  for  at  least  two  years,  and  most  of  them  for  four  years  or  more.  Of 
the  14,  10  were  cured,  i  relapsed,  and  3  died  ;  one  of  these  last  three  had  an 
immediate  operation  just  at  the  end,  when  death  was  already  imminent. 
Ochsner,  by  the  analysis  of  a  mass  of  figures,  concludes  that  half  of  the  cases 
treated  medically  get  well ;  but  that  half  of  these  relapse  later,  so  that  only  a 
quarter  are  finally  cured.  Borchgrevink  followed  up  17  cases  treated  medically  ; 
3  of  these  died,  and  14  were  well  for  two  years  or  more. 

It  is  quite  useless  to  set  these  figures  up  as  an  alternative  to  those  obtained 
by  surgical  intervention ;  for  the  great  majority  of  the  patients  treated 
medically  are  handed  over  to  a  surgeon  as  soon  as  it  becomes  evident  that  they 
are  not  doing  well ;  and  it  is  quite  certain,  therefore,  that  the  Bristol  cases  and 
Borchgrevink's,  for  instance,  are  much  too  favourable,  representing,  as  they  do, 
only  those  patients  who  are  not  bad  enough  to  be  operated  on. 

In  an  orphan  asylum  in  Bristol,  where  the  physician  preferred  to  treat  all 
cases  medically,  6  were  cured  and  3  died  ;  they  were  all  well  cared  for  from  the 
first,  and  obtained  plenty  of  fresh  air,  good  food,  and  skilled  nursing  ;  so  that 
these  results  are  probably  too  favourable.  In  dealing  with  this  disease,  the 
worst  statistical  reports  are  more  likely  to  be  correct  than  the  best.  It  is 
probably  fair  to  accept  Faludi's  view,  that  about  one-third  will  recover,  and 
two-thirds  will  eventually  die,  apart  from  surgical  intervention. 

Results  of  Operation. — These  Eire  much  easier  to  obtain  with  some  degree  of 
reliability,  though  here  also  there  is  a  tendency  to  report  too  soon.  Most  of 
the  figures  are  taken  from  hospital  records,  and  may  therefore  be  trusted.  In 
Caird's  and  Borchgrevink's  and  in  the  Bristol  series,  the  patients  were  followed 
for  more  than  two  years  ;  in  Czerny 's,  the  majority  were  followed  over  three 
years,  but  others  for  a  lesser  period  ;  Ochsner's  and  Bottomley's  were  traced 
for  one  year  only. 

Results  of  Operation  for  Tuberculous  Peritonitis. 


Eeporter 

Cases  operated 
on 

Died  within 
a  month 

Cases 
followed 

Cured         Relapsed  or 
not  cured 

Died  later 

Bottomley    - 

Borchgrevink 

Czerny  - 

Ochsner 

Matteson 

Caird     - 

Bristol  hospitals  - 

41 

32 
53 
31 
33 

3 

1 
0 
3 

7* 

24 
22 
38 
20 
37 
17 
20 

11 
13 

18 
15 
17 
8 
11 

2 
0 
9 
0 
0 

I 

11 

9 

11 

5 

20 

9 

7 

Total      - 

190 

14 

178 

! 

93        1        13        I        72 

'°'c?nfr    i<o^'Percent)|    (°Ve'nfr 

394 


INDEX     OF     PROGNOSIS 


It  \\'ill  be  observed  that  the  immediate  mortality  varies  a  good  deal ;  the 
Bristol  cases  included  two  deaths  from  intestinal  obstruction,  one  from  ileo- 
sigmoidostomy,  and  one  from  perforative  peritonitis,  and  are  therefore  too  high. 
The  true  mortality  of  the  operation,  in  properly  selected  cases,  is  not  more 
than  I  or  2  per  cent. 

With  the  exception  of  Ochsner's  series,  which  is  reported  too  soon,  the  end- 
results  are  much  the  same  everywhere  ;  it  -will  be  seen  that  rather  more  than 
half  are  well  for  two  years  or  more  ;  40  per  cent,  approximately,  die  of  some 
form  of  tuberculosis  ;  and  a  certain  small  number  relapse,  or  are  little  improved. 
This  agrees  with  the  conclusions  of  Fenger,  but  is  less  favourable  than  those  of 
Faludi,  who  claims  that  of  125  operation  cases,  70  per  cent  were  '  cured  '  ;  but 
we  do  not  know  for  how  long. 

The  Mayos  claim  excellent  results  bj'  remo\'ing  tuberculous  tubes  in  adult 
females. 

We  may  sum  up,  therefore,  by  saying  that,  on  an  average,  about  a  third  of 
the  patients  will  be  cured  by  medical  means  ;  and  of  those  that  come  to  opera- 
tion, about  half  will  be  permanently  freed  from  their  trouble.  Inasmuch, 
however,  as  the  first  of  these  figures  is  little  better  than  a  guess,  the  value  of 
operation  is  not  very  securely  established. 

Prognosis  in  Individual  Cases. — There  does  not  appear  to  be  much  difference 
between  the  results  in  adults  and  children.  Febrile  cases  are  said  to  do  better 
than  afebrile  (Borchgre\'ink).  The  more  acute  the  onset,  the  worse  the  pro- 
gnosis (RoUeston). 

The  type  of  the  disease  is  of  very  great  importance  in  this  respect.  The 
ascitic  type,  with  abundant  free  fluid,  but  no  adhesions,  does  best.  The  ulcerous 
type,  with  great  wasting,  a  huge  abdomen,  irregular  temperature,  and  tendency 
to  diarrhoea,  only  recovers  in  quite  exceptional  cases.  A  faecal  fistula  is  practi- 
cally a  death-warrant.  The  fibrous  or  adhesive  type  is  intermediate.  Most  of 
the  operation  figures  given  refer  to  the  ascitic  type. 

Bottomley  and  Matteson  both  distinguish  between  the  results  of  operation 
on  the  different  kinds,  as  shown  in  the  follo\\'ing  table. 


Mortality  accordixg  to  Type  of  Peritonitis. 


ASCITIC  Type 

Fibrous  Type 

Ulcerous  type 

Beporter 

Cases 

Died 

Cases 

Died 

Cases 

Died 

Bottomley     - 
Matteson 

16 
29 

7 
10 

7 
24 

3 

18 

— 

1 

Grave  signs,  in  any  particular  case,  are  marked  wasting  in  spite  of  treatment, 
uncontrollable  diarrhoea,  and  evidence  of  pulmonary  tuberculosis. 

In  fatal  cases,  death  usually  takes  place  in  six  months  to  two  years  ;  those 
surviving  the  latter  period  are  likely  to  recover.  It  is  remarkable  how  it  occa- 
sionally happens  that  even  a  badly  matted  abdomen  may  eventually  get  well. 

The  causes  of  death  are  intestinal  obstruction,  perforative  peritonitis, 
exhaustion  from  diarrhoea  or  Isecal  fistula,  and  generalized  tuberculosis. 

References. — Fenger,  Ann.  Surg.  1901,  xxxiv,  771  ;  Bottomley,  Boston  City  Hasp. 
Med.  and  Surg.  Rep.  1900,  118  ;  Ochsner,  Trans.  Amer.  Assoc.  Surg.  1902,  191  ; 
Matteson,  Providence  Med.  Jour.  1911,  6;  Caird,  Edin.  Med.  Jour.  1912,  viii,  295; 
Discussion,  B.M.A.,  Brit.  Med.  Jour.  1911,  ii,  473-  A.  Rendle  Short. 


PERNICIOUS    ANEMIA  395 

PERNICIOUS  ANEMIA. — There  are  few  conditions  in  which  the  practitioner 
of  medicine  finds  more  scope  for  the  exercise  of  liis  prognostic  powers  than  in 
pernicious  anaemia.  Death  may  occur  within  a  fortnight  after  the  patient  comes 
under  observation,  and,  on  the  other  hand,  a  fatal  issue  may  be  delayed  for 
frwenty  years ;  but  in  spite  of  this  very  wide  range  of  possibihties,  the  skilled 
observer  may  be  able  to  assign  nearly  every  case  to  a  place  in  the  acute,  the 
subacute,  or  the  chronic  group,  the  characters  and  course  of  which  are  fairly 
definite.  Even  after  cases  have  been  assigned  to  their  appropriate  class,  a 
careful  review  of  general  symptoms,  together  with  a  thorough  examination  of 
the  blood,  will  enable  the  practitioner  to  make  further  refinements,  and  he  can 
often  predict  the  course  of  the  indi\ddual  case  with  xery  considerable  accuracy. 
One  of  the  remarkable  features  of  the  disease  is  the  occurrence  of  remissions. 
They  sometimes  begin  quite  abruptly,  even  although  severe  symptoms  may  be 
present,  and  their  occurrence  is  often  attributed  to  the  exhibition  of  medicines 
which  had  no  part  in  bringing  about  the  improvement. 

Remissions  may  last  for  months  or  even  years.  A  patient  may  undergo  as 
many  as  half  a  dozen  remissions  and  relapses.  During  the  remissions,  the  chief 
abnormal  characteristics  of  the  blood  may  disappear ;  but  in  many  cases  a  rather 
high  colour-index,  or  some  other  special  feature,  may  persist  ;  the  remission 
may  be  complete  as  regards  disappearance  of  symptoms.  This  is  particularly 
likely  in  the  case  of  remission  following  a  first  attack  ;  after  subsequent  attacks, 
remissions  are  less  likely  to  be  complete,  and  the  patient  is  most  likely  to  remain, 
at  the  best,  in  a  condition  approaching  or  exemphfying  semi-invalidism. 

History. — It  is  of  prime  importance  to  take  into  account  the  cause  of  the 
disease.  If  the  cause  can  be  discovered  and  removed,  the  outlook  is  good.  If 
not,  the  disease  will  sooner  or  later  prove  fatal. 

The  cases  due  to  Bothriocephahts  latus  can  practically  all  be  cured. 

Cases  which  begin  during  pregnancy  and  the  puerperium  are  likely  to  recover 
if  the  very  dangerous  period  during  which  the  symptoms  are  acute  can  be  safely 
tided  over.  Some  cases  appear  to  be  due  to  cancer  of  the  stomach.  Little  hope 
can  be  held  out  in  these,  as  there  is  no  likelihood  of  a  remission,  and  without 
a  remission  of  the  ansmia,  operation  would  be  out  of  the  question,  ^^^len  no 
cause  can  be  discovered,  we  must  judge  of  the  case  on  the  lines  laid  down  in 
connection  with  the  blood  changes. 

Another  important  point  in  connection  with  the  history  is  the  question  of 
whether  or  not  we  are  dealing  with  a  first  attack.  Not  onlj'  is  the  chance  of 
a  remission  greater  after  a  first  than  after  a  subsequent  attack,  but  after  a 
first  one  there  is  a  much  greater  likehhood  that,  if  a  remission  does  occur,  it  will 
be  more  complete  and  more  prolonged  than  after  a  second  or  subsequent  relapse. 
Due  regard,  however,  must  be  paid  to  the  kind  of  attack.  A  patient  suffering 
from  pernicious  anaemia  of  a  definitely  chronic  t^'pe,  although  he  never  reaches 
a  high  standard  of  health,  has  a  better  expectation  of  life  than  the  patient  who 
has  had  more  than  one  acute  attack  with  an  intervening  period  of  apparent 
health.  Most  cases  have  their  type  stamped  upon  them  early.  In  all,  there  is 
a  historj^  of  very  insidious  onset.  In  cases  of  chronic  tj^pe,  the  disease  gradually 
advances  till  an  extreme  degree  of  weakness  is  reached.  In  acute  cases,  the 
more  urgent  symptoms  come  on  rapidly,  but  are  usually  a  sequel  to  a  slowly 
progressive  departure  from  health. 

Blood  Changes. — In  a  case  doing  badly,  the  behaviour  of  the  blood  will  vary 
a  good  deal  according  to  the  acuteness  or  chronicity  of  the  disease. 

In  the  acute  cases,  the  tendency  is  for  the  corpuscles  to  diminish  steadily  in 
number,  and  for  the  colour-index  to  rise  or  remain  high.  More  and  more  megalo- 
blasts  may  appear,  and  these  are  often  at  their  maximum  just  before  death. 


396  INDEX     OF     PROGNOSIS 

It  is  impossible  to  make  any  statement  as  to  the  lowest  red-cell  count  com- 
patible with  life.  Many  cases  die  before  the  count  has  fallen  below  1,000,000 
per  c.mra.  In  these  it  is  hardly  likely  that  the  anaemia,  per  se,  is  the  cause  of 
death.  Renal  inadequacy,  a  pneumonic  patch,  and  a  variety  of  other  complica- 
tions whose  existence  may  give  rise  to  no  obvious  symptoms,  often  play  an 
important  part  in  determining  the  fatal  issue.  We  have  seen  a  case  recover 
where  the  red  cells  had  fallen  to  400,000.  The  patient  in  question  was  practically 
comatose  for  nearly  a  fortnight,  and  then  had  a  remission  which  lasted  eighteen 
months.  Quincke's  count  of  143,000  has  never  been  equalled  ;  the  patient 
in  that  case  recovered.  Our  own  lowest  count  was  200,000,  but  it  was  made  only 
a  few  hours  before  death. 

In  cases  which  are  going  to  recover,  the  red  corpuscles  sometimes  increase 
with  startUng  rapidity.  There  may  be  a  rise  of  a  milUon  a  week,  although 
that  is  exceptional.  The  colour-index,  if  it  has  been  high,  gradually  drops. 
The  corpuscles  improve  in  quality ;  they  become  smaller,  basophilia  and 
polychromasia  lessen,  and  megaloblasts  disappear.  A  recent  case  in  point 
was  a  lady,  aged  40,  whose  first  count  was  800,000,  haemoglobin  25  per  cent, 
colour-index  i  -5.  Three  successive  counts  at  intervals  of  a  week  read  :  1,050,000, 
30  per  cent,  1-3  ;    2,300,000,  55  per  cent,  i-ig  ;    3,280,000,  58  per  cent,  o-g. 

Some  of  these  cases  reach  a  perfectly  normal  count  in  every  way,  and  often 
pass  through  a  stage  during  which  the  colour-index  is  low.  It  may  drop  to  0-7 
and  remain  below  unity  for  weeks.  This  is  to  be  interpreted  as  a  return  to  the 
normoblastic  type  of  blood-formation  in  the  marrow,  and  is  an  excellent  prog- 
nostic sign.  If  the  leucocytes  at  the  same  time  show  a  tendency  to  rise  to  the 
normal  level  of  7,000  per  c.mm.,  so  much  the  better. 

A  certain  number  of  cases  never  reach  normal  figures  for  either  red  or  white 
cells.  Many  of  them  have  a  short  period  of  comparative  health  and  soon  drop 
back  again  to  a  condition  of  serious  illness.  Others  become  chronic  cases  and 
may  last  a  very  long  time,  with  blood-counts  far  from  satisfactory,  but  with  a 
wonderful  degree  of  freedom  from  subjective  symptoms  or  active  discomfort. 

We  have  been  accustomed  to  group  cases  of  pernicious  anaemia  as  follows, 
mainly  in  respect  of  the  blood  condition. 

1.  Acute  Favourable  Cases. — The  symptoms  are  marked.  Red  corpuscles 
are  diminished,  but  repeated  counts  indicate  a  tendency  to  rise.  Megaloblasts 
are  not  very  numerous  and  are  mostly  of  pyknotic  type.  Normoblasts  are 
present.  The  colour-index,  on  repeated  examination,  shows  a  tendency  to  fall. 
Polychroma.sia  is  not  marked.  The  percentage  of  polymorphonuclear  cells  is 
fairly  high  and  the  white-cell  count  is  not  greatty  diminished.  Myelocytes  are 
absent  or  few. 

In  these  cases  a  remission  to  a  fairly  normal  condition  may  be  expected, 
and  the  remission  may  last  for  years  or  months. 

2.  Acute  Unfavourable  Cases. — Symptoms  are  very  marked.  Red  cells 
number  about  a  million,  and  repeated  counts  reveal  a  tendency  to  fall.  Megalo- 
blasts are  typical,  large,  and  numerous.  Normoblasts  are  very  few  or  absent. 
The  colour-index  is  high.  Polychromasia  is  marked.  The  percentage  of  lympho- 
cytes is  high  and  the  total  leucocyte  count  is  low.     Myelocytes  are  numerous. 

In  these  cases  a  fatal  termination  is  to  be  expected  in  less  than  three  months, 
and  it  may  occur  in  less  than  three  weeks. 

3.  Subacute  Cases. — Symptoms  are  fairly  well  marked.  Red  cells  are  usually 
just  over  a  million,  showing  considerable  variations  in  number  in  successive 
counts.  Megaloblasts  are  fairly  numerous.  Normoblasts  are  scanty.  The 
colour-index  is  high.  Polychromasia  is  present.  The  percentage  of  lympho- 
cytes is  high,  but  polymorphs  may  incrgiase  during  a  febrile  attack.  Myelocytes 
are  fairly  numerous. 


PERNICIOUS     ANEMIA  397 

The  average  duration  of  these  cases  is  about  two  years.  Intercurrent  disease 
or  acute  exacerbations  usually  terminate  the  case. 

4.  Chronic  Cases. — Symptoms  are  not  well  marked.  Red  cells  tend  to  remain 
about  one  and  a  half  or  two  milUons.  Megaloblasts  are  scanty  or  absent.  Nor- 
moblasts are  rarely  seen.  The  colour-index  is  about  unity.  Polychromatophilia 
is  slight.  Basophihc  stippling  is  seldom  seen.  The  percentage  of  lympho- 
cytes is  high.     Myelocytes  are  scanty  or  absent. 

Such  cases  are  often  fit  to  work  for  perhaps  six  months  in  the  year. 
Their  chief  trouble  is  weakness.  Febrile  attacks  may  occur,  but  seem  to  have 
little  effect.  Nerve  symptoms  are  fairly  common,  but  their  incidence  does  not 
affect  prognosis.  Improvement  is  rare,  but  the  patient  may  live  for  many 
years. 

Not  infrequently  we  are  unable  to  make  this  classification  as  the  result  of  a 
single  blood  examination.  In  some  of  the  acute  cases  it  may  be  imipossible  to 
say  whether  the  outlook  is  favourable  or  otherwise.  In  these,  a  second  examina- 
tion in  a  week's  time  will  often  clear  up  the  difficulty. 

Thus,  a  case  where  the  red  corpuscles  are  under  one  million  per  c.mm.  rarely 
continues  long  at  that  stage  ;  if  at  the  end  of  a  week  they  have  shown  a  tendency 
to  fall,  we  may  predict  a  fairly  early  termination  ;  on  the  other  hand,  if  the 
tendency  of  the  corpuscles  is  to  rise,  we  generally  find  that  our  case  will  undergo 
a  remission.  Further,  we  may  expect  that  if  the  symptoms  have  been  severe, 
with  fever,  yellow  colour,  etc.,  the  remission  will  be  very  satisfactory,  especially 
if  the  attack  is  the  first  one.  A  case  of  more  chronic  type,  and  especially  a  case 
in  a  second  or  later  relapse,  is  more  hkely  to  make  less  rapid  progress,  and  the 
improvement  will  be  from  invalidism  to  semi-invalidism  rather  than  to  an 
appearance  of  complete  health. 

When  a  case  is  at  its  worst,  a  very  slight  alteration  in  the  blood-count  may 
have  a  very  important  significance.  A  rise  of  300,000  red  cells  per  c.mm.  in  a 
week  would  almost  be  sufficient  to  justify  the  hope  of  a  remission,  and  a  pre- 
ponderance of  the  type  of  megaloblast  with  small,  deeply-staining  (pyknotic) 
nucleus,  rather  than  the  type  with  large  nucleus  and  open  chromatin  network, 
would  also  be  a  very  favourable  sign. 

Symptoms. — The  incidence  of  such  symptoms  as  sickness  or  diarrhoea,  increase 
of  the  yellow  tint  or  oedema,  does  not  necessarily  affect  the  ultimate  course  of 
the  disease,  though  any  of  these  would  add  to  the  gravity  of  a  case  in  an  acute 
attack. 

Febrile  attacks  add  to  the  gravity  of  the  condition  while  they  last.  The 
patient  may  be  none  the  worse,  and  is  sometimes  better,  after  they  are  over. 

Haemorrhages  are  a  serious  sign.  It  has  been  suggested  that  retinal  hnsmor- 
rhages  are  not  so  serious  prognostically  as  others. 

We  recently  saw  a  case  where  pernicious  anaemia  was  complicated  by  bleeding 
fibroids.  Each  haemorrhage  was  definitely  lowering  the  blood-count.  There 
were  megaloblasts,  polychromasia,  and  basophilic  stippUng  of  the  red  corpuscles. 
The  counts  were  red  corpuscles  1,370,000,  haemoglobin  56  per  cent,  leucocytes 
4400,  colour-index  1*3.  We  advocated  operation,  and  hysterectomy  was  success- 
fully performed.  A  week  after  operation  the  red  corpuscles  numbered  1,600,000, 
haemoglobin  43  per  cent. 

The  onset  of  jaundice  is  a  somewhat  serious  symptom.  It  is  probable  that 
all  cases  suffer  from  some  renal  inadequacy.  The  evidence  of  this  is  based  on 
our  post-mortem  experience  ;  when  there  is  chnical  evidence  of  kidney  disease, 
the  prognosis  becomes  much  more  serious,  except  occasionally  in  the  puerperal 
cases. 

Any  compUcation  of  an  inflammatory  nature  nearly  always  determines  a  fatal 


398  INDEX     OF     PROGNOSIS 

issue.  Patches  of  catarrhal  pneumonia  may  be  present  without  cUnical  sym- 
ptoms, owing  to  the  failure  of  the  patient  to  react.  When  they  are  discovered, 
they  are  to  be  regarded  as  likely  to  shorten  the  patient's  life. 

Other  complications  do  not  greatly  disturb  the  course  of  the  disease.  One 
case  of  ours,  a  lady  with  a  red-cell  count  of  3,500,000,  and  haemoglobin  72  per 
cent,  underwent  an  operation  for  gall-stones  with  no  ill  effect. 

Treatment. — There  is  little  doubt  that  cases  placed  in  favourable  surroundings 
have  a  better  chance  of  a  remission  or  recovery  than  those  not  so  fortunately 
placed.  Hospital  treatment  for  the  poor,  and  skilled  nursing  for  the  well-to-do, 
may  make  all  the  difference  between  a  favourable  and  an  unfavourable  result. 

The  patient  who  can  take  life  easily  after  a  first  attack  is  in  an  infinitely  better 
position  as  regards  expectation  of  life  than  one  who  has  to  return  to  either  mental 
or  physical  work. 

As  regards  medicine,  no  drug  can  yet  be  said  to  compete  seriously  with 
arsenic,  and  an  important  element  in  prognosis  is  the  way  the  patient  responds 
to  it,  and  the  manner  in  which  it  is  tolerated.  Patients  who  can  take  such  doses 
as  15  minims  of  Fowler's,  or  a  similar,  solution,  thrice  daily,  are  almost  certain  to 
do  well. 

The  various  organic  preparations  of  arsenic — cacodylate  of  soda,  atoxyl, 
soamin,  arsacetin,  etc. — give  no  better  results  than  Fowler's  solution  or  the 
liq.  arsenici  hydrochlor.,  and  in  our  experience  they  cause  more  frequent  and 
more  severe  toxic  results  than  the  pharmacopoeial  preparations. 

Many  observers  have  published  the  results  of  treatment  by  salvarsan.  Among 
those  who  have  been  favourably  impressed  with  this  drug  is  Byrom  Bramwell,^ 
who  has  published  the  result  of  11  cases.  In  4  there  was  a  return  to  health,  in 
2  there  was  marked  improvement,  and  in  i  slight  improvement ;  2  showed  no 
improvement  and  2  died.  The  salvarsan  was  injected  into  the  buttock,  and  there 
was  a  slight  febrile  reaction  in  most  of  the  cases.  Boggs^  has  also  reported  the 
result  of  salvarsan  treatment  in  11  cases.  Of  these,  2  were  practically  mori- 
bund before  treatment,  and  died.  The  remaining  g  cases  improved.  A  large 
number  of  cases  have  been  reported  by  other  observers  ;  in  many  instances 
the  results  are  not  nearly  so  favourable  as  the  foregoing.  Our  own  experience 
is  not  encouraging ;  we  have  treated  13  cases  with  intravenous  injections 
of  salvarsan,  and  7  cases  with  intramuscular  injections  of  neo-salvarsan ;  the 
intravenous  injections  were  always  followed  by  a  febrile  reaction  and  often  by 
gastro-intestinal  disturbance.  Of  the  salvarsan  cases,  7  died,  3  improved,  and  3 
remained  in  statu  quo  ;  of  the  neo-salvarsan  cases,  4  died,  i  improved,  and  2 
seemed  to  be  unaffected.  We  do  not  think  it  can  be  maintained  that  the  intro- 
duction of  these  drugs  has  in  any  way  improved  the  prognosis. 

Iron  does  harm  rather  than  good  in  most  cases  of  pernicious  anaemia  ;  some- 
times it  does  good  when  the  colour-index  is  low  during  the  course  of  recovery. 

Washing  out  the  bowel  with  normal  saline  solution  is  a  measure  which  may  be 
said  to  improve  the  patient's  prospects  of  recovery.  The  administration  of 
intestinal  antiseptics  is  not  of  such  proved  benefit. 

Among  other  measures  which  have  been  suggested  are  the  administration  of 
bone-marrow,  the  injection  of  antistreptococcus  serum,  and  transfusion  of  blood. 
We  have  never  been  able  to  satisfy  ourselves  that  bone-marrow  does  any  good. 
In  the  published  successful  cases  it  has  generally  been  given  along  with  arsenic 
or  other  medicines,  and  the  mere  transference  of  a  patient  from  an  unfavourable 
environment  to  hospital  might  be  enough  to  determine  a  remission,  especially 
in  the  case  of  a  first  attack.  This  explanation  probably  partly  accounts  for  the 
successes  which  have  been  attributed  to  antistreptococcus  serum,  the  other 
factor  being  a  possible  benefit  from   the  serum  itself,  not  from  its  antistrepto- 


PLACENTA     PRMVIA  399 


coccus  element.  We  have  never  seen  a  case  in  which  benefit  could  be  attributed 
to  its  use  apart  from  these  considerations,  and  we  have  certainly  seen  cases  in 
which  it  did  harm. 

We  have  had  cases  which  improved  after  a  course  of  injections  of  normal  horse 
serum.  We  have  never  seen  anaphylactic  symptoms  in  these  cases,  and  if  arsenic 
fails  completely,  it  is  worth  trying. 

Transfusion  of  blood  is  a  measure  which  is  usually  reserved  for  desperate 
cases.  We  have  had  one  or  two  apparently  brilliant  successes  and  many 
failures.  Where  there  are  urgent  reasons  for  attempting  to  prolong  the  life 
of  a  hopeless  case  for  a  week  or  so,  it  is  a  measure  which  may  justifiably  be 
tried. 

As  we  have  indicated  in  an  earlier  part  of  this  article,  cases  of  pernicious 
ansmia  seem  to  stand  surgical  operations  surprisingly  well,  but  the  reasons  for 
sanctioning  any  operation  must  always  be  clamant. 

References. —  ^Brit.  Med.  Jour.  1913,  May  24  ;  ^ Johns  Hop.  Hosp.  Bull.  191 3,  Oct. 

G.  L.  Gulland. 
A.  Goodall. 
PERTUSSIS.— (See  Whooping-cough.) 

PHLEBOTOMUS  FEVER.— (See  Tropical  Fevers.) 

PHTHISIS. — {See  Pulmonary   Tuberculosis.) 

PILES. — [See  H.-emorrhoids.) 

PLACENTA  PREVIA. — The  prognosis  of  placenta  praevia  varies  with 
several  factors,  of  which  the  more  important  are :  the  period  of  gestation  at 
which  the  bleeding  incidental  to  the  vicious  situation  of  the  placenta  takes 
place ;  the  degree  of  dilatation  of  the  cervical  os ;  and  the  type  of  placenta 
praevia.  In  general  it  may  be  said  that  cases  occurring  before  labour  are  of 
more  serious  import  than  those  occurring  coincidently  with  the  onset  of  labour 
pains.  Also,  the  more  central  the  placenta,  the  sooner  its  separation  occurs  in 
the  period  in  which  the  expansion  of  the  lower  uterine  segment  proceeds. 
Thus,  in  cases  in  which  the  bleeding  begins  before  the  onset  of  labour,  there 
is  more  likelihood  that  the  practitioner  has  to  deal  with  a  placenta  entirely 
covering  the  external  os.  This  in  itself  is  serious ;  but  the  outlook  is  rendered 
more  grave  by  the  fact  that  the  obstetrician,  in  his  efforts  to  arrest  the  bleed- 
ing, is  confronted  with  an  undilated  cervix. 

In  estimating  the  prognosis  of  any  individual  case,  the  state  of  the  patient 
when  she  first  came  under  treatment,  and  the  correct  selection  of  the  proper 
method  of  treatment  suitable  to  that  case,  have  both  to  be  taken  into  account. 

There  are  three  principal  methods,  each  of  which  is  warmly  championed  by 
certain  authorities,  but  each  of  which,  to  be  successful,  has  its  own  sphere. 
These  are  (i)   Ccesarean  section  ;    (2)  T)e  Ribes'  bag  ;    (3)  Podalic  version. 

I.  Caesarean  Section. — This  is  undoubtedly  the  best  method  under  certain 
definite  circumstances — namely,  when  (a)  The  haemorrhage  has  not  been 
excessive  ;  (6)  The  cervix  is  not  dilated  ;  (c)  The  placenta  is  central  ;  and 
{d)  The  child  is  alive. 

With  regard  to  the  first  of  these,  it  is  important  to  bear  in  mind  that  where 
a  woman  is  already  in  extremis  from  loss  of  blood,  rapid  emptying  of  the  uterus 
gives  rise  to  a  degree  of  shock  that  may  be  fatal.  As  regards  the  second,  it 
it  is  obvious  that  by  extracting  the  child  through  an  abdominal  incision,  the 
difficulties  that  attend  measures  applied  through  an  undilated  os  are  avoided  : 
in   fact,   bleeding  is   absolutely   controlled   from   the   moment   of   opening   the 


400  INDEX     OF     PROGNOSIS 

abdomen.  Further,  the  undilated  condition  of  the  cervix  probably  means 
that  the  uterus  is  free  from  infection,  which  is  the  chief  source  of  danger  in 
Csesarean  section. 

Some  figures  of  the  more  recent  results  may  be  given.  The  number  of  cases 
in  which  Caesarean  section  has  been  performed  makes  a  comparatively  small 
total.  Routy  has  collected  the  following  figures  :  In  43  cases  by  American 
surgeons  there  were  7  deaths,  or  16-3  per  cent ;  in  26  cases  by  Kronig  and 
Sellheim  there  were  no  deaths.  The  wide  variation  in  the  results  is  to  be 
attributed  to  the  number  of  operators  in  the  first  series.  Bumm  has  performed 
vaginal  Caesarean  section  in  15  cases,  with  i  death. 

It  is  in  the  saving  of  the  life  of  the  offspring  that  Caesarean  section  shows  so 
much  better  results.  Thus,  in  the  26  cases  performed  by  Kronig  and  Sellheim, 
all  the  children  survived. 

2.  De  Ribes'  Hydrostatic  Bag. — The  use  of  de  Ribes'  bag  is  eminently 
successful  in  suitable  cases,  such  as  a  patulous  os,  early  in,  or  before,  labour, 
and  in  those  cases  in  which  it  can  be  ascertained  that  the  placenta  does  not 
cover  the  internal  os  completely.  It  is  therefore  applicable  to  a  large  majority 
of  cases  of  placenta  praevia  ;  it  is  inferior  to  Csesarean  section  in  the  results  of 
the  latter  under  certain  specified  conditions  ;  but  in  emergency  it  supplies  a 
means  of  treating  even  these  cases,  when  the  conditions  and  the  requirements 
for  Caesarean  section  are  lacking. 

The  results  of  treatment  by  the  bag  vary  considerably  in  difierent  hands. 
In  a  group  of  cases  undertaken  under  the  ordinary  conditions  of  life,  it  will  be 
found  that  the  mortality  ranges  between  6  and  8  per  cent  of  all  cases.  If,  on 
the  other  hand,  figures  are  taken  from  special  obstetrical  hospitals,  where  there 
is  a  routine  carefully  followed  and  where  the  chief  personally  directs,  the 
mortality  is  found  to  be  as  low  as  2-18  per  cent  in  Pinard's  clinic  and  2-1  per 
cent  in  the  clinic  of  Kronig.  The  foetal  mortality  varies  widely,  but  ranges 
between  40  and  70  per  cent,  the  average  figure  being  60  per  cent. 

3.  Podalie  Version. — Turning  the  child  is  strongly  recommended  by  certain 
authors  as  giving  better  results,  and  being  more  constantly  effective,  than  the 
use  of  de  Ribes'  bag.  It  is  perhaps  specially  indicated  in  those  cases  in  which 
by  the  time  the  case  is  seen  dilatation  of  the  os  is  advanced.  Further,  in  the 
aljsence  of  a  de  Ribes'  bag,  there  is  no  doubt  that  this  procedure  forms  a  good 
substitute. 

When  the  results  are  compared  with  those  of  the  bag,  it  is  seen  that  the 
average  is  nearly  as  good  ;  but  the  best  figures  of  skilled  obstetricians  do  not 
come  up  to  the  best  with  de  Ribes'  bag.  Thus  the  Rotunda  statistics  quoted 
by  Tweedy-  show  a  mortality  of  5-3  per  cent  in  no  cases  during  the  years  1903- 
1910  ;  but  of  the  41  delivered  in  hospital,  there  was  only  i  death,  or  2-5  per 
cent,  which  compares  very  favourably  with  the  results  of  the  use  of  the  hydro- 
static bag.  There  is  no  doubt  that  the  foetal  mortality  is  higher  in  this  method 
— 60  to  80  per  cent ;  but  of  course  it  depends  to  a  certain  extent  upon  the 
advancement  of  gestation  and  the  time  of  commencement  of  treatment. 

In  comparing  the  three  methods  of  treatment,  it  should  be  remembered  that 
in  the  majority  of  cases  the  champion  of  podalie  version  as  against  de  Ribes' 
bag,  or  vice  versa,  has  become  expert  in  that  form  of  treatment ;  there  ought 
however,  to  be  a  special  field  for  each  method — when  its  proper  application  will 
lead  to  a  successful  result.  Caesarean  section  will  become  more  extensively 
used  in  the  future  ;  at  present  many  obstetricians  would  limit  its  application 
to  about  5  per  cent  of  cases. 

The  morbidity- rate  of  all  cases  is  given  by  Ellice  MacDcnald^  as  26  per  cent. 
The  most  important  complication  is    sepsis,   which  is  responsible  for  a  fatal 


PLEURITIS  401 

termination  in  at  least  60  per  cent  of  the  deaths.  Next  is  thrombosis  of  uterine 
veins  and  swelling  of  the  leg.  It  is  found  that  septic  complications  occur  in 
14  per  cent  of  cases. 

The  more  immediate  cause  of  death  is  the  shock  of  rapid  or  rough  delivery, 
superimposed  on  great  loss  of  blood  during  labour. 

The  foetal  deaths,  in  cases  where  the  child  is  viable,  are  due  partly  to 
premature  separation  of  the  placenta  and  partly  to  asphyxia  during  a  breech 
delivery. 

In  conclusion,  the  following  figures  may  be  taken  as  indicating  the  results  of 
all  cases  of  placenta  praevia,  irrespective  of  the  treatment  adopted  :  In  10,600 
cases  collected  by  Ellice  MacDonald,^  the  maternal  mortality  was  7-7  per  cent 
and  the  foetal  mortality  55  per  cent  (the  maternal  mortality  in  the  year  1877 
was  23  per  cent).  Edgar*  records  40  cases,  with  a  maternal  mortality  of  7-5  per 
cent  and  a  foetal  mortality  of  32  per  cent. 

References. — ^Jour.  Obst.  and  Gyn.  1911,  Jan.  ;  ^Ibid.  1913,  Aug.  ;  ^Surg.  Gyn. 
and  Obst.  1911,  June  ;    ^Amer.  Jour,  of  Obst.  1911,  July.  firj,rfen  Glendining. 

PLEURITIS.' — The  immediate  prognosis  of  pleuritis  is  good  ;  the  remote 
prospects  are  not  so  satisfactory.  An  investigation  of  the  examples  of  this 
disease  admitted  to  St.  Bartholomew's  Hospital  from  1899  to  1903  showed  that 
the  average  length  of  treatment  amounted  to  a  little  over  three  weeks  in  cases 
without  effusion,  and  to  rather  less  than  five  weeks  in  cases  with  effusion. 

The  Immediate  Prognosis. — This  varies  with  (i)  The  nature  of  the  organism  ; 
(2)  The  age  of  the  patient ;  (3)  The  amount  of  fluid  present ;  and  {4)  The 
associated  conditions. 

1.  Nature  of  the  Organism.- — Out  of  49  cases  of  pleural  effusion  examined 
from  a  bacteriological  standpoint  at  St.  Bartholomew's  Hospital,  40  were  found 
to  be  sterile  and  therefore  presumably  tuberculous,  7  were  associated  with  the 
pneumococcus,  and  2  with  the  streptococcus.  Other  organisms  which  have  been 
found  in  this  condition  are  the  Bacillus  typhosus,  Pfeiffer's  bacillus,  and  the 
gonococcus.  There  is  a  greater  tendency  to  the  formation  of  pus  in  the  case  of 
the  pneumococcus  and  streptococcus. 

2.  Age  of  the  Patient. —  In  children  and  young  adults  the  immediate  dangers  of 
pleuritis,  whether  with  or  without  effusion,  are  small,  and  the  mortality  is 
probably  less  than  2  per  cent. 

3.  Amount  of  Fluid  Present. — The  amount  of  fluid  present  when  the  case 
comes  under  observation  has  a  definite  bearing  on  the  mortality.  The  danger 
of  death  from  a  small  effusion  is  practically  nil  ;  but  fluid  which  is  present  to 
such  an  extent  that  it  reaches  above  the  second  rib  causes  positive  pressure  upon 
the  heart  and  lungs,  and  so  may  cause  death.  Other  causes  of  death  in  pleural 
effusion  are  thrombosis  of  the  right  heart  and  pericardial  effusion.  The  presence 
of  fine  rales  on  the  unaffected  side  is  associated  with  a  graver  prognosis.  Gee 
and  Horder  state  that  651  cases  of  pleuritis  between  the  years  1884  and  1893 
gave  a  mortality  of  io'3  per  cent ;  whilst  783  cases  between  the  years  1894  and 
1903  gave  a  mortality  of  1-4  per  cent.  Thus  1434  cases  were  associated  with 
a  mortality  of  4"!  per  cent.  The  great  difference  between  the  mortality  of  the 
two  series  is  attributed  to  improved  methods  of  treatment,  and  especially  to  the 
earlier  adoption  of  aspiration  in  the  latter  series. 

4.  Associated  Conditions.^ — -Pleuritis  as  a  complication  of  existing  disease  is 
of  graver  significance  than  pleuritis  occurring  in  a  previously  healthy  person. 
Thus  pleuritis  in  pulmonary  tuberculosis  denotes  an  extension  of  the  original 
disease  ;  whilst  in  chronic  diseases  such  as  Bright's  disease  it  is  of  grave  signifi- 
cance, and  is  not  infrequently  caused  by  the  onset  of  tuberculosis.     Extension 

26 


402  INDEX     OF     PROGNOSIS 

of  the  inflammation  to  the  pericardium  tends  to  prolong  the  duration  of  the 
illness,  but  does  not  add  greatly  to  the  immediate  mortality. 

End-results. — The  remote  prospects  of  pleuritis,  whether  dry  or  with 
effusion,  are  chiefly  concerned  with  the  question  whether  the  cause  of  the  original 
inflammation  is  the  tubercle  bacillus  or  not.  The  proportion  of  cases  of  pleuritis 
which  are  due  to  the  tubercle  bacillus  is  considerable.  Some  French  observers 
put  the  percentage  as  high  as  75  ;  few  physicians  put  it  lower  than  30. 
Lord  followed  up  55  out  of  82  patients  he  had  observed,  and  found  that  7  had 
died  from  pulmonary  tuberculosis,  8  were  suffering  from  this  disease,  and  40 
were  well.  He  further  found  that  25  per  cent  continued  to  complain  of 
occasional  pleuritic  pains. 

Fiedler  found  that  of  92  cases  of  acute  pleuritis  with  effusion,  there  had  been 
28  deaths  from  pulmonary  tuberculosis  at  the  end  of  two  years,  and  that  only 

21  of  the  remaining  patients  appeared  to  be  healthy.    Barr  found  that  in  six  years 

22  patients  out  of  62  had  died  from  pulmonary  tuberculosis.  Cabot  had  117 
deaths  in  five  years  out  of  300  cases  ;  whilst  Hedges  found  that  out  of  130  cases, 
tuberculosis  developed  in  40  per  cent  in  seven  years.  These  figures  are  supported 
by  two  other  lines  of  observation  :  (i)  A  positive  tuberculin  reaction  is  stated 
to  be  present  in  75  per  cent  of  cases  of  pleuritis  with  effusion  ;  (2)  At  least 
18  per  cent  of  the  cases  of  pulmonary  tuberculosis  admitted  to  the  chest  hospitals 
in  London  have  a  history  of  pleuritis  two  or  more  years  before. 

The  practical  deduction  is  that  a  large  number  of  cases  of  pleuritis  can  be 
demonstrated  to  have  a  tuberculous  origin,  and  that  an  even  greater  proportion 
are  due  to  this  cause.  In  view  of  the  great  frequency,  subsequently,  of 
pulmonary  tuberculosis  in  these  cases,  it  is  not  too  much  to  say  that  every 
primary  case  of  pleuritis,  whether  with  or  without  effusion,  should  be  regarded 
as  tuberculous,  unless  the  contrary  can  be  proved.  If  this  were  done,  and  all 
such  cases  were  treated  for  some  time  on  sanatorium  lines,  together  with  tuber- 
culin, a  great  step  would  be  taken  in  diminishing  the  incidence  of  pulmonary 
tuberculosis.  My  own  experience  in  this  direction  is  most  satisfactory  ;  and 
I  am  tempted  to  express  the  opinion  that  primary  pleuritis,  when  regarded  as 
a  comparatively  trivial  affection,  is  associated  in  later  years  with  a  high  mortality 
from  pulmonary  tuberculosis  ;  whereas,  when  it  is  adequately  treated  from  the 
commencement  as  being  tuberculous,  the  after-results  are  almost  as  good  as 
the  immediate  ones.  Arthur  Latham. 

PNEUMOCOCCIC  PERITONITIS. — There  are  two  very  definite  types  of  this 
rather  uncommon  disease,  the  prognosis  in  the  one  being  extremely  grave,  and 
in  the  other  remarkably  favourable.  These  are  (i)  The  diffuse  or  acute  type,  and 
(2)  The  encysted  or  chronic.  Either  of  these  may  or  may  not  have  been  preceded 
by  an  attack  of  pneumonia.  The  diagnosis  can  only  be  regarded  as  certain  when 
the  pneumococcus  is  found  either  at  operation  or  autopsy,  or,  in  a  few  cases,  when 
the  pus  leaks  away  at  the  umbilicus. 

I.  Acute  Diffuse  Pneumoeoecie  Peritonitis. — Of  the  91  cases  from  the  literature 
reported  by  Annand  and  Bowen,  46  belonged  to  this  variety.  Of  16  cases  at  the 
Bristol  Royal  Infirmary  and  General  Hospital,  12  were  acute. 

The  patients  are  almost  all  little  girls.  They  present  the  clinical  picture  of  an 
acute  general  peritonitis  of  rapid  onset,  usually  accompanied  by  a  marked 
tendency  to  diarrhoea.  In  about  half  the  cases  there  is  evidence  of  pneumonia 
beginning  a  day  or  two  previously.  The  diagnosis  of  appendicitis  with  general 
peritonitis  is  usually  made,  but  there  is  no  special  localization  of  pain  or  tender- 
ness in  the  right  iliac  fossa. 

The  prognosis  is  very  grave  indeed.     Rischbieth  quotes  45  cases,  all  of  which 


PNEUMONIA 


403 


died.  Of  the  Bristol  cases,  11  out  of  12  died.  Of  6  cases  at  St.  Bartholomew's 
Hospital,  all  died.  In  Annand  and  Bowen's  series,  6  recovered  and  40  died.  All 
the  Bristol  cases  except  2,  both  fatal,  were  operated  on  ;  in  Annand  and 
Bowen's  list,  18  were  operated  on  and  6  recovered.  The  prognosis  is  not  greatly- 
affected  by  the  question  as  to  whether  there  has  been  a  previous  pneumonia 
or  not.     If  death  is  going  to  occur,  it  is  usually  within  a  few  days. 

In  practice,  it  might  be  very  difficult  to  give  a  prognosis  because  of  the 
uncertainty  of  the  diagnosis  before  operation ;  but  when  there  is  generalized 
tenderness  of  the  abdomen  with  marked  rigidity,  pain,  fever  and  diarrhoea,  the 
only  diagnoses  reasonably  probable  in  a  little  girl  are  perforative  appendicitis  and 
this  disease,  and  in  both  the  outlook  is  very  grave  with  immediate  operation, 
and  almost  hopeless  without.  One  should  make  certain  that  there  is  not  a 
gonorrhoeal  vulvo-vaginitis  present,  because  gonorrhoeal  peritonitis  is  decidedly 
more  favourable. 

2.  Chronic  Encysted  Pneumococcic  Peritonitis. — In  this  very  interesting  and 
remarkable  disease,  one  is  confronted  with  the  strange  sight  of  a  large  cavity 
in  the  abdomen  containing,  it  may  be,  pints  of  pus,  surrounded  by  intestines, 
liver,  and  stomach  all  matted  together,  and  yet  the  patient  is  singularly  little 
affected.  In  one  of  three  cases  seen  by  the  writer,  the  abscess  quietly  burst  at 
the  umbilicus  before  the  girl  was  sent  to  hospital ;  in  two  others,  sisters,  the 
temperature  was  but  little  raised,  and  the  patients  did  not  look  ill.  They  came 
under  observation  about  a  week  after  the  onset  of  the  abdominal  pain  and 
swelling,  and  both  had  had  pneumonia.  The  pus  has  not  an  offensive  odour, 
and  is  thick  and  creamy. 

The  great  majority  of  the  cases  are  operated  on  and  recover.  In  Annand  and 
Bowen's  series  of  45,  the  result  was  known  in  43,  and  of  these  37  recovered.  Only 
one  of  these  was  not  operated  on  ;  in  this  patient  the  pus  burst  forth  at  the 
umbilicus,  and  recovery  took  place.  All  4  Bristol  cases  of  this  encysted  variety 
recovered  ;  one  of  them  has  subsequently  developed  abdominal  pain,  presumably 
due  to  adhesions. 

Probably  the  majority  of  the  cases  of  pneumococcic  peritonitis  at  St.  Thomas's 
Hospital,  1907-igii,  were  of  this  type,  inasmuch  as  9  out  of  16  were  cured. 

Pneumococcic   Peritonitis. 


^Annand and  Bowen,  operated  - 
j  „  not  operated - 

Acute  diffuse  form-'.  Bristol 

St.  Bart.'s  Hosp. 
^Rischbieth 

All  cases  St.  Thomas's  Hosp.  1907-1911 

Chronic    encysted    ( Annand  and  Bowen 


form 


1  Bristol 


18 
28 
12 

45 

16 

43 
4 


6=33-3% 

0=0% 

1=8-33% 

0=0% 

0=0% 

9=56-29  % 

37=86% 
4=100  % 


Died 


12=66-6% 
28=100% 
11=91-66% 
6=100  % 
45=100% 

7=43-8% 

6=14  % 
0=0% 


References. — Annand  and  Bowen,  Lancet,  1906,  i.  1591  ;  Rischbieth,  Quar.  Jour. 
Med.  1911  ;  Noon  and  Moreton,  St.  Bart.'s  Hosp.  Rep.  1912,  137  ;  St.  Thomas's  Hosp. 
Rep.  1907-1911.  ^_  Rendle  Short. 


PNEUMONIA.- — The  mortality  from  pneumonia  when  taken  over  a  consider- 
able number  of  years  amounts  to  about  i  in  5,  or  20  per  cent.  Thus,  Wells 
collected  465,400  cases  with  a  mortality  of  94,826,  or  20-4  per  cent  ;  Osier  and 
McCrae  collected  43,555  cases  with  a  mortality  of  21  per  cent  ;  in  the  7868  cases 
which  occurred  in  the  London  general  hospitals  during  ten  years,  there  was   a 


404 


INDEX     OF     PROGNOSIS 


mortality  of  21  per  cent  ;  in  1065  cases  of  the  Collective  Investigation  Committee 
of  London,  the  mortality  was  i  in  5 '5.  Even  when  the  causes  which  are 
associated  with  a  high  mortality  in  this  disease — such  as  intemperance,  mental 
and  physical  deformities,  infectious  cases,  old  age — are  allowed  for,  the  mortality 
appears  to  be  T  in  8. 

The  character  of  the  epidemic,  that  is  to  say,  the  virulence  of  the  causal  organism, 
affects  the  mortality,  as  it  may  affect  the  character  of  the  complications.  Thus, 
the  673  cases  observed  in  the  Middlesex  Hospital  from  1880  to  1889  showed 
a  mortality  of  17  per  cent  ;  but  when  the  different  years  were  compared,  the 
mortality  varied  from  12  to  24  per  cent.  This  explains  why  such  widely  different 
results  are  given  when  the  effect  of  different  treatments  are  compared  over  a 
comparatively  small  number  of  cases.  For  example,  some  authors  claim  a 
mortality  of  as  little  as  2  per  cent,  whilst  others  confess  to  a  mortality  of  over 
30  per  cent.  As  bearing  on  this  point,  I  would  mention  that  I  have  known  five 
people  die  from  pneumonia  in  one  house  within  a  fortnight.  Tyson  quotes  an 
epidemic  in  a  ship's  crew,  in  which  298  cases  out  of  720  ended  fatally. 

In  a  similar  way  the  character  of  the  epidemic  may  affect  the  complications  : 
thus,  in  three  months  I  saw  pneumonia  followed  by  abscess  of  the  lung  in  no  less 
than  seven  cases. 

As  regards  age,  it  would  appear  that  pneumonia  is  especially  fatal  to  children 
under  two  years  of  age,  and  to  old  people.  With  regard  to  children,  Gossage  in 
observing  986  cases  under  ten  years  of  age  found  a  mortaUty  of  13 '8  per  cent. 
Of  these,  cases  under  two  years  of  age  gave  a  mortality  of  26'4  per  cent  ;  whilst 
above  this  age  it  was  only  6"2  per  cent.  These  figures  are  borne  out  by 
most  observers  ;  and  in  most  epidemics  of  pneumonia,  children  of  from  five  to 
ten  years  of  age  have  the  disease  in  a  mild  form,  which  often  aborts  on  the  fourth 
day.  I  have  seen  recovery  in  one  case  at  the  age  of  fourteen  from  a  typical 
attack  where  it  was  stated  that  the  child  had  had  fifteen  or  more  similar  attacks. 

Varioiis  factors  influence  the  prognosis.  The  mortality  in  hospital  cases  is 
greater  than  in  private  practice  :  in  drunkards  it  is  probably  at  least  double. 
Although  women  are  less  frequently  attacked  than  men,  it  is  stated  that  their 
mortality  is  greater.  Again,  the  mortality  is  greater  in  negroes  than  in  white 
people,  in  debihtated  persons  than  in  those  previously  robust,  and  is  much 
increased  when  there  is  associated  disease  such  as  arteriosclerosis,  severe  cardiac 
affections,  chronic  nephritis,  or  diabetes. 

With  regard  to  the  position  and  extent,  it  is  stated  that  right-sided  lesions  are 
more  fatal  than  those  on  the  left,  and  it  is  generally  held  that  apical  lesions  are 
"more  dangerous  than  basal  ones,  more  especially  in  attacks  during  old  age.  The 
-extent  of  lung  involved  affects  the  result,  but  appears  to  exert  rather  less  influence 
than  might  be  expected,  as  may  be  seen  in  the  following  tables  of  Osier  and 
IMcCrae: — 

Mortality  as  affected  by  Extent  of  Lung  involved. 


1  lobe  involved  in  21  per  cent 

2  lobes      ,,  ,,  38        ,, 

3  »  ,-  ,-  31        ,- 

4  „  „  „       0        „ 


Non-fatal  Cases 


1  lobe  involved  in  40  per  cent 

2  lobes        ,,        ,,  33        ,, 

3  ,,  M         M  20 

4  „  „         „        1        » 


The  effect  of  complications  has  no  great  bearing  on  the  total  mortality  from 
pneumonia,  as  they  are  comparatively  speaking  uncommon.     Their  effect  on 


PNEUMONIA 


405 


the  cases  in  which  they  occur  is  greater.  Thus,  of  the  7868  cases  observed  in 
the  London  hospitals,  there  were  only  290  cases  of  empyema,  or  yj  per  cent, 
of  which  88  were  fatal,  or  about  30  per  cent  ;  125  cases  of  pleural  effusion,  or 
I '6  per  cent,  of  which  13  were  fatal,  or  about  10  per  cent.  Pericarditis  only 
occurred  in  i  per  cent  of  these  cases,  but  of  the  fatalities  10  per  cent  were 
associated  with  this  complication.  In  children,  convulsions  in  the  early  stages 
have  Httle  significance,  but  in  the  later  stages  they  are  associated  with 
a  higher  death-rate.  Herpes  is  held  to  be  a  favourable  sign  :  thus,  Gisseler 
noted  the  presence  of  herpes  in  182  out  of  421  cases,  and  found  the  mortality 
less  when  this  complication  occurred. 

The  degree  of  toxcemia  and  the  reaction  to  it  are  really  the  most  important  factors 
in  estimating  the  outlook  in  a  given  case  of  pneumonia.  For  practical  purposes 
these  must  usually  be  estimated  from  a  consideration  of  the  temperature,  pulse, 
and  respiration.  The  following  tables  of  Prebles  on  the  relation  of  the 
temperature,  pulse,  and  respiration-rate  on  the  mortality,  are  therefore  of 
interest : — 

Temperature  and  Mortality. 


Temperature 

Cases 

Deaths 

Percentage 

Under  100" 

17 

6 

35-2 

102° 

220 

52 

23-1 

103° 

302 

83 

27-4 

104° 

408 

109 

26-7 

105° 

386 

99 

26 

106° 

148 

45 

30-5 

Over  106° 

34 

23 

68 

Pulse-rate  and  Mortality. 


Pnlse 

Cases 

Deaths 

Percentage 

Under    100 

57 

2 

3-5 

110 

123 

7 

5-7 

120 

142 

18 

12-6 

130 

288 

62 

21-5 

140 

143 

68 

47 

150 

125 

74 

59 

Over     150 

83 

64 

77 

Respiration-rate  and  Mortality. 


liespiration 

Cases 

Deaths 

Percentage 

Under    30 

77 

6 

7-7 

40 

247 

36 

14 

50 

384 

116 

30-2 

60 

123 

62 

50-4 

70 

98 

61 

62-2 

Over       70 

23 

14 

65-6 

It  will  be  seen  that  when  the  temperature  is  low — i.e.,  below  100° — or  above 
105°,  the  mortality  is  greater  than  the  average  ;    that  when  the  pulse  is  above 


4o6  INDEX     OF     PROGNOSIS 


130  the  mortality  is  more  than  doubled  ;  and  that  when  the  respirations  are 
more  than  50  the  mortahty  is  50  per  cent  or  more. 

If  the  infection  causes  little  response,  as  is  often  the  case  in  old  people,  and 
the  temperature  remains  low,  the  outlook  is  grave  ;  if  the  infection  is  severe  and 
causes  marked  toxcemia,  as  shown  by  temperature,  pulse,  and  respiration,  the 
mortahty  is  greatl}^  increased  ;  but  when  the  infection  is  met  wdth  an  adequate 
response,  and  the  temperature  is  below  105°,  the  pulse-rate  below  T30,  and  the 
respiration-rate  below  40,  the  mortahty  is  about  i  in  5. 

The  action  of  the  heart,  and  especially  of  the  right  ventricle,  is  always  significant. 
When  the  right  heart  becomes  distended,  and  the  pulse  in  addition  to  being 
rapid  becomes  irregular,  the  outlook  is  grave.  When  auricular  fibrillation 
occurs  during  the  attack,  even  though  the  crisis  may  appear  to  have  been  safely 
passed,  the  case  always  ends  fatally. 

Although  the  outlook  may  appear  hopeless,  treatment — especially  with 
cardiac  and  respiratory  stimulants  such  as  alcohol,  digitalis,  and  strs-chnine — 
should  be  continued  and  pushed  until  a  definite  effect  is  obtained,  for  in  no 
disease  are  there  so  many  recoveries  from  an  apparently  ine\'itable  death. 

Different  forms  of  treatment,  such  as  the  use  of  vaccines,  the  systematic  employ- 
ment of  digitalis,  or  the  use  of  various  other  methods,  have  not  been  shown  to 
have  any  markedly  different  results  in  a  sufficiently  large  number  of  cases. 
Patients  moved  to  hospital  on  the  first  day  of  the  disease  appear  to  have  a  better 
prognosis  than  those  moved  on  the  third  or  fourth.  This  is  probably  explained 
by  the  eftect  of  movement  in  inducing  excessive  auto-inoculations  as  in  other 
cases  of  bacterial  infection,  and  emphasizes  the  necessity  of  hmiting  the  move- 
ments and  examination  of  the  patient  as  much  as  possible  during  the  acute  stage 
of  the  disease. 

Those  who  suffer  from  an  attack  of  pneumonia  not  infrequently  have  another 
attack  later  in  hfe.  Some  authors  put  this  tendency  to  a  second  attack  at  as 
high  a  figure  as  50  per  cent.  Arthur  Latham. 

PNEUMOTHORAX. — The  prognosis  differs  greatly  according  to  the  cause, 
and  the  condition  of  the  patient  in  whom  it  occurs. 

In  the  spontaneous  form,  which  is  chiefly  dependent  on  the  presence  of  emphy- 
sema, infective  agencies  are  absent,  and  consequently  one  of  the  most  serious 
compUcations  is  absent  also.  Further,  in  this  form,  effusion  is  rarely  found.  In 
58  cases  studied  by  Fussell  and  Rissman,  efl"usion  only  occurred  in  one  instance. 
Adams,  however,  reported  a  case  in  which  effusion  lasted  for  four  years.  The 
outlook  in  this  form  of  pneumothorax  is  good,  and  recovery  is  the  rule,  pro\T.ded 
the  general  condition  of  the  patient  is  good.  It  may  occur  in  a  week,  or  it  may  be 
delayed  for  several  months.  In  Fussell  and  Rissman's  series  only  one  death 
resulted.  On  the  other  hand,  pneumothorax  as  a  compUcation  of  advanced 
emphysema,  with  severe  overtaxing  of  the  heart,  is  a  grave  complication  and 
usually  fatal. 

In  the  traumatic  form,  the  prognosis  depends  chiefly  on  the  character  of  the 
wound,  and  more  especially  on  the  question  whether  septic  complications  occur. 
In  the  absence  of  sepsis  the  outlook  is  good.  Cases  which  occur  as  the  result  of 
thoracentesis  usuaUy  do  well. 

Cases  in  which  pneumothorax  is  due  to  the  perforation  of  the  lung  by  an  empyema, 
often  do  well  after  the  necessary  surgical  measures  have  been  taken. 

Cases  associated  with  gangrene,  rupture  of  septic  infarcts,  or  bronchiectasis  are, 
practically  speaking,  always  fatal. 

Pneumothorax  occurring  in  a  case  of  pulmonary  tuberculosis  is  usually  attended 
with  a  grave  outlook,  as  it  is   most  commonly  met  with  when  the  disease  is 


POL  YC  YTH^MIA  407 


advanced  and  both  lungs  are  extensively  affected.  Samuel  West,  as  the  result 
of  observations  on  toi  cases,  gives  the  mortality  as  being  about  70  per  cent  ; 
Saussier  recorded  a  fatal  result  in  131  out  of  147  cases,  that  is  to  say,  a  percentage 
of  go.  Of  58  cases  of  pneumothorax  collected  from  the  post-mortem  records 
of  the  Brompton  Hospital,  the  greatest  duration  of  life  was  twelve  years,  the 
least  duration  ten  minutes.  On  the  other  hand,  cases  with  a  much  longer 
duration  are  on  record.  Dr.  Williams  reported  a  case,  occurring  in  his 
private  practice,  in  which  life  was  prolonged  for  twenty-one  years. 

It  would  appear  that  recovery  may  take  place  in  from  10  to  25  per  cent  of 
cases  ;  and  further,  that  in  a  small  number  of  instances  the  occurrence  of  pneumo- 
thorax may  be  beneficial  to  the  patient,  leading  to  arrest  of  the  disease,  in  the 
same  way  as  the  artificial  compression  of  the  lung  by  nitrogen  is  sometimes 
followed  by  great  improvement  or  complete  recovery.  I  have  personally  seen 
recovery  after  pneumothorax  with  arrest  of  the  tuberculous  disease  in  two  cases. 

The  prognosis  in  pneumothorax  is  therefore  bad,  when  viewed  as  a  whole. 
Whether  it  is  immediately  associated  with  fatal  results  depends  on  the  extent 
of  the  primary  disease  and  the  general  condition  of  the  patient,  that  is,  his 
capacity  to  withstand  the  great  shock  which  is  caused  by  the  production  of  this 
complication.  The  practice  of  removing  the  air  from  the  distended  pleura  at  an 
early  stage  has  certainly  decreased  the  immediate  mortality.  If  the  pneumo- 
thorax is  sharply  limited  by  adhesions,  and  small  in  extent,  it  may  be  without 
effect  on  the  duration  of  life,  and  even  escape  notice  at  the  time  of  its  production  ; 
but  in  the  case  of  a  general  pneumothorax  the  chief  consideration  at  the  time 
it  is  produced  is  the  effect  of  the  immediate  shock. 

If  the  stage  of  shock  is  survived,  the  chief  considerations  in  estimating  the 
prognosis  are  the  general  condition  of  the  patient,  the  extent  of  disease  in  the 
other  lung,  and  the  occurrence  of  septic  complications.  When  a  hydropneumo- 
thorax  has  become  established,  the  condition  remains  unchanged  usually  for 
months,  or  exceptionally  for  years.  It  is  rare,  however,  for  complete  recovery 
to  take  place  under  these  conditions,  as  the  primary  disease  usually  continues 
to  extend.  Bven  if  pyopneumothorax  supervene,  the  patient  may  live  for 
several  years.  Arthur  Latham. 

POISONING,  ARSENIC— (See  Arsenic  Poisoning.) 

POISONING,  LEAD.— (5ee  Lead  Poisoning.) 

POISONING,  MERCURIAL.— (5ee  Mercurialism.) 

POLIOMYELITIS,    ACUTE    ANTERIOR.— (See    Infantile    Paralysis.) 

POLYCYSTIC  KIDNEY.— (See  Kidney,  Polycystic.) 

POLYCYTHEMIA   (SPLENOMEGALIC   POLYCYTHiEMIA,  ERYTHREMIA). 

— This  disease  is  rare,  and  few  observers  have  had  sufficient  experience  to  lay 
down  very  definite  statements  regarding  its  probable  course. 

Many  cases  show  little  change,  either  for  better  or  worse,  for  prolonged  periods. 

Temporary  exacerbations  of  the  cyanosis  may  occur  and,  on  the  otlier  hand, 
periods  of  remission  of  symptoms  have  been  recorded. 

Complications  are  not  very  common.  Erythromelalgia  has  been  noted  in 
several  cases.  Haemorrhages  are  not  infrequent,  but  as  a  rule  their  efifect  is 
beneficial  to  the  patient. 

Many  intercurrent  affections  may  arise.  Among  those  which  have  been 
recorded  are  jaundice  and  cirrhosis  of  the  liver,  valvular  disease  of  the  heart, 


4o8  INDEX     OF    PROGNOSIS 

arteriosclerosis,  thrombosis  and  cerebral  haemorrhage,  bronchitis  and  emphysema, 
kidney  disease,  and  affections  of  the  central  nervous  system.  Other  complications 
which  have  been  reported  have  no  apparent  connection  with  the  polycythsemia. 

A  fatal  outcome  is  usually  associated  with  an  exacerbation  of  the  cyanosis, 
a  vascular  complication,  or  an  inflammatory  intercurrent  affection. 

No  special  line  of  treatment  appears  to  influence  the  course  of  the  disease, 
though  symptoms  may  be  alleviated. 

Venesection  has  been  followed  by  benefit,  especially  when  the  blood-pressure 
is  high.  The  results  of  application  of  x  rays  have  been  inconstant.  A  diet 
poor  in  iron  has  been  tried  with  some  degree  of  success.  No  benefit  is  to  be 
expected  from  splenectomy.  G.  L.  Gulland. 

A.  Goodall. 

PREGNANCY,  ALBUMINURIA  OF.— [See  Albuminuria  of  Pregnancy.) 

PREGNANCY,    ECTOPIC— (5ee  Ectopic  Pregnancy.) 
PREGNANCY,  VOMITING  OF.— {See  Vomiting  of  Pregnancy.) 
PROGRESSIVE  MUSCULAR  ATROPHY.— (5ee  Muscular  Atrophies.) 
PROLAPSUS  RECTI. — (See  Rectal  Prolapse.) 

PROSTATE,  CANCER  OF.— About  one-fifth  of  the  cases  of  enlargement  of 
the  prostate  are  due  to  cancer.  An  excellent  study  of  iii  cases  was  published  a 
few  years  ago  by  Young.  ^ 

The  course  is  very  variable.  A  few  die  within  a  year,  the  majority  in  from 
two  to  three  years  ;  but  a  remarkably  large  number  live  for  three  or  four  years, 
and  a  few  live  more  than  five.  Some  patients  have  had  bladder  trouble  for 
twenty  years,  so  it  is  probable  that  the  cancer  may  start  in  a  prostate  which 
is  the  subject  of  a  simple  hypertrophy.  There  is,  therefore,  frequently  plenty 
of  time  in  which  to  undertake  diagnosis  and  treatment  before  the  growth  becomes 
irremovable. 

Treatment. — So  far,  the  results  are  not  very  decisive.  The  cases  are  wholly 
unsuitable  for  suprapubic  enucleations  ;  4  out  of  11  such  patients  at  St.  Thomas's 
Hospital  died. 

Young's  perineal  route  gives  better  results.  His  radical  operation,  with  -wide 
removal,  has  apparently  cured  2  patients  out  of  6,  these  being  well  four  and  six 
years  respectively  ;  another  lived  three  years.  Out  of  19  patients  treated  by  his 
ordinary  method,  as  used  for  simple  cases,  all  but  4  obtained  some  relief  ;  2 
lived  in  comfort  for  two  and  three  years  respectively,  and  2  others  were  apparently 
cured,  i  being  well  so  long  as  six  years  afterwards. 

In  39  cases,  catheter  life  was  instituted,  with  no  operation.  It  often  became 
very  difficult,  and  out  of  23  cases  followed,  only  3  lived  two  years. 

Reference. —  ^Young,  Atm.  Surg.  1909,  1,  1144.  A.  Rendle  Short. 

PROSTATE,  HYPERTROPHY  OF. — We  shall  here  speak  only  of  cases  of 
simple  overgrowth  of  the  prostate,  reserving  malignant  affection  of  the  gland 
for  a  separate  article. 

Prognosis  apart  from  Operation. — It  must  be  borne  in  mind  that  enlarge- 
ment of  the  prostate  is  a  progressive  disease.  Acute  exacerbations  due  to 
inflammation  may  subside  under  treatment,  but  we  have  no  means  of  checking 
the  steady  growth.  When  symptoms  have  once  appeared,  therefore,  there  is  a 
tendency  for  them  to  get  worse  instc.d  of  better.  In  a  fair  proportion  of  cases 
seen,  however,  a  fortunate  man  may  live  for  years  with  or  without  the  regular 
use  of  a  catheter,  any  advance  in  the  size  of  the  prostate  being  very  slow  indeed. 


PROSTATE,     HYPERTROPHY     OF  409 


Much  depends  on  the  person's  age  ;  in  an  old  man,  senile  decay  may  intervene 
before  the  prostatic  trouble  proves  fatal ;  whereas,  in  a  patient  in  the  fifties,  and 
in  good  general  health,  difficulties  with  micturition  and  urcemia  are  likely  to 
shorten  life  very  considerably.  The  most  favourable  cases  are  those  in  which, 
owing  to  some  definite  cause,  such  as  lack  of  opportunity  to  pass  water  on  a  long 
journey,  an  attack  of  acute  retention  is  precipitated.  After  a  few  days  of  rest 
and  catheterism,  voluntary  power  of  micturition  may  be  regained  for  years. 

Ordinarily,  there  are  five  successive  stages  :  (i)  Difficulty  in  micturition,  with 
straining  ;  (2)  Frequency  of  micturition,  seriously  interfering  with  sleep  ; 
(3)  Acute  or  chronic  retention  of  urine,  necessitating  the  occasional  or  regular 
use  of  the  catheter  ;  (4)  Chronic  cystitis  ;  the  discomfort  and  frequency  now 
get  much  worse  ;    (5)   Septic  infection  of  the  kidneys,  leading  to  uraemia. 

The  total  course  varies  so  much  that  one  can  only  form  a  prognosis  by  judging 
each  patient's  prospects  separately.  Unintelligent  old  men  often  present  them- 
selves, obviously  but  a  few  weeks  before  the  inevitable  fatal  termination,  and 
give  a  history  of  bladder  troubles  only  within  the  past  month  or  so.  On  the  other 
hand,  a  patient  may  have  symptoms  of  an  enlarged  prostate  for  eight  or  ten 
years,  but  this  is  unusually  favourable. 

Many  patients  pass  into  an  extremely  miserable  condition.  Their  morale  may 
become  unhinged,  and  offences  against  decency  may  ruin  their  reputation. 
Later,  great  frequency  of  micturition,  pain,  haematuria,  loss  of  sleep,  and  calculus 
formation  due  to  ammoniacal  fermentation  of  the  urine,  wear  out  their  strength. 
When  marked  cystitis  and  frequency  are  present,  the  patient  has,  in  the  majority 
of  cases,  not  many  months  to  live,  apart  from  surgical  intervention.  Loss  of 
appetite,  thirst,  sweating,  emaciation,  urinous  breath,  tendency  to  catheter-fever, 
and  polyuria  with  urea  output  below  15  grams  a  day,  show  that  uraemia  has 
already  begun,  and  death  is  not  far  off.  Retention  is  a  sign  of  some  gravity 
unless  most  carefully  treated  ;  it  leads  frequently  to  cystitis  ;  and  if  all  the  urine 
is  drawn  off  at  once  from  a  patient  with  chronic  retention,  fatal  suppression  of 
urine  is  not  at  all  uncommon,  owing  to  the  dilated  ureters  allo^^■ing  a  sudden  fall 
of  pressmre  in  the  renal  pelves. 

In  estimating  the  prognosis  apart  from  operation,  therefore,  one  has  to  take 
into  account  : — (i)  The  patient's  age,  bearing  in  mind  that  the  younger  the  man 
is,  the  more  will  his  natural  expectation  of  life  be  shortened  ;  (2)  The  apparent 
rate  of  progress  ;  (3)  His  intelligence  and  skill  in  using  a  catheter,  and  keeping  it 
clean  ;  and  (4)  The  question  of  cystitis,  or  of  signs  of  ummia.  The  question  of 
malignancy  really  enters  into  the  prognosis  also,  because  it  is  impossible  to  make 
a  certain  diagnosis  at  first,  and  one  case  in  five  of  prostatic  enlargement  is 
cancerous.  It  is  all  but  certain  that  cancer  may  supervene  on  a  simple  hyper- 
trophy. 

Prognosis  as  regards  Operation. — Of  operations  for  enlarged  prostate, 
we  may  mention  suprapubic  enucleation,  perineal  prostatectomy ,  Bottini's  operation, 
the  bar-punch  operation,  castration,  and  vasectomy.  We  may  say  at  once  that  the 
two  last  named  are  almost  extinct. 

Vasectomy  was  simple  and  harmless,  but  seldom  produced  a  lasting  cure. 

Castration  was  more  successful,  perhaps,  in  reducing  the  size  of  the  prostate, 
but  it  often  failed,  and  was  frequently  very  repugnant  to  the  patient,  had  a 
decided  mortality,  and  led  to  mental  disturbance  in  a  distressingly  large  number 
of  cases.  No  doubt  it  was  too  often  resorted  to  in  old  men  who  were  already 
marked  for  death. 

Suprapubic  Prostatectomy. — Largely  o\\'ing  to  the  teaching  of  Freyer,  this  is 
the  customary  operation  in  England,  the  perineal  route  being  the  favourite  on 
the  Continent  and  in  America. 


41  o  INDEX     OF    PROGNOSIS 

The  7nortality-rate  is  bound  to  vary  much,  according  to  the  condition  of  the 
patient  at  the  time  the  operation  is  undertaken,  and  there  is  a  great  difference 
between  the  figures  which  could  be  quoted.  Freyer,  in  1912,  reported  a  series 
of  1000  cases  with  only  55  deaths,  but  at  the  same  meeting  Hey  Groves  stated 
that  the  death-rate  in  English  hospitals,  for  the  year  1907,  was  40  per  cent !  This 
latter  figure  is  undoubtedly  too  high  at  the  present  day,  because  hospital  surgeons 
are  not  now  so  ready  to  operate  in  one  stage  upon  patients  whose  kidneys  are 
already  affected,  and  general  practitioners  are  beginning  to  send  in  cases  that 
are  not  yet  in  extremis.  The  English  hospital  statistics  at  the  present  time 
show  a  death-rate  of  about  20  per  cent.  At  two  Bristol  hospitals,  during  the 
years  1906  to  1912,  it  was  decidedly  higher  than  this,  early  cases  being  few. 
Out  of  68  patients,  24  died,  a  mortality  of  35  per  cent.  At  "  one  of  the  largest 
hospitals,"  according  to  Wade,  out  of  164  operation  cases  in  ten  years  54  died, 
that  is,  35  per  cent.  At  St.  Thomas's  Hospital,  1906  to  1910,  of  69  cases,  14 
died,  a  mortality  of  20-3  per  cent ;  and  at  four  other  London  hospitals  during 
the  same  period,  16  died  out  of  76.  It  must  be  remembered  that  many  of  the 
patients  who  succumbed  in  hospital  were  already  desperately  ill ;  and  the 
genuinely  favourable  cases  are  not  very  well  represented,  because  many  surgeons 
do  not  recommend  operation  to  patients  who  could  be  treated  by  catheterization. 

In  the  hands  of  individual  surgeons  who  prefer  operation  to  the  catheter,  and 
whose  material  includes  a  large  proportion  of  cases  derived  from  private  practice, 
the  mortality  is  much  lower.  Freyer,  as  already  mentioned,  lost  55  out  of  1000 
cases.  Thomson  Walker,  in  a  series  of  over  100,  had  a  death-rate  of  5  per  cent. 
Yet  both  these  surgeons  claim  to  have  accepted  bad  cases  ;  Thomson  Walker 
declares  that  he  exercised  practically  no  selection,  except  in  cases  where  any  sort 
of  operation  would  obviously  be  foolhardy,  and  Freyer  remarks  that  many  of  his 
patients  were  desperately  ill,  usually  more  or  less  dependent  on  the  catheter, 
few  were  free  from  cystitis,  181  had  vesical  calculus  (of  these,  8-5  per  cent  died), 
and  62  were  octogenarians. 

We  may  conclude,  therefore,  that  the  mortality  of  suprapubic  prostatectomy 
would,  in  capable  hands,  be  well  below  5  per  cent  in  patients  with  sound 
kidneys  and  little  or  no  cystitis. 

The  causes  of  death  are  uremia  (24  out  of  Freyer's  55  fatalities),  shock  or 
heart  failure,  and  chest  complications. 

The  end-results  of  suprapubic  prostatectomy  are  no  doubt  remarkably  good. 
Freyer  claims  that  every  case  of  his  surviving  the  operation  has  a  perfect  result, 
except  one  patient  with  atony  of  the  bladder  ;  he  has  never  seen  retention, 
incontinence,  fistula,  or  loss  of  sex-power.  He  does  not,  however,  give  data 
showing  how  many  patients  were  seen  or  heard  from  at  any  considerable  period 
after  the  operation.  He  claims,  and  all  surgeons  will  corroborate  the  statement, 
that  atony  of  the  bladder,  even  when  it  appears  to  have  already  come  on, 
recovers  wonderfully  after  removal  of  the  prostate. 

Thomson  Walker  has  carefully  studied  112  cases  of  his  own,  followed  for  at 
least  eighteen  months.  The  results  were  as  follows  :  Incontinence  of  urine,  o  ; 
atony  of  bladder,  2  ;  loss  of  sexual  functions,  1 1 ;  cystitis,  occasionally  persists  ; 
development  of  vesical  calculus,  6  ;  suprapubic  fistula,  2  ;  suprapubic  hernia,  2  ; 
recurrent  haemorrhage,  i.  All  the  rest  were  restored  to  perfect  health  ;  and  it 
must  be  remarked  that  in  the  atony  cases,  in  most  of  those  with  loss  of  sexual 
functions,  and  in  three  out  of  the  six  cases  of  stone,  the  trouble  was  but  a 
persistence  or  recurrence  of  the  pre-operative  condition.  One  of  the  fistula 
patients  was  cured  by  a  second  operation.  It  will  be  observed  that,  omitting 
the  patients  with  impotence,  cystitis,  or  calculus,  105  out  of  112  were  cured. 

Of  26  patients  treated  at  St.   Thomas's   Hospital  and  followed  up,   20  did 


PROSTATE.     HYPERTROPHY     OF 


411 


excellently,  2  developed  a  stone,  3  had  incomplete  control  (two  of  these  were 
possibly  cancerous),  and  i  had  a  suprapubic  fistula. 

Of  32  cases  operated  on  in  two  Bristol  hospitals,  24  were  perfectly  well,  and 
2  were  only  troubled  by  some  degree  of  frequency.  Of  the  others,  2  patients 
developed  a  stone,  and  in  i  of  these  the  suprapubic  opening  failed  to  close  ; 
2  had  some  incontinence  ;  and  in  3  patients  there  was  little  or  no  relief,  straining 
and  difficulty  persisting  ;  one  or  two  of  these  were  possibly  cancerous.  All  these 
were  followed  at  least  a  year. 

The  sexual  functions  were  wholly  lost  in  only  12-5  per  cent  of  Thomson  Walker's 
cases  ;  many  of  these  were  aged  men,  and  in  some  there  was  impotence  or  loss 
of  desire  before  operation. 

Perineal  Prostatectomy. — This  operation  is  performed  in  several  different 
ways,  some  of  which  do  not  conserve  the  membranous  urethra  as  well  as  others  ; 
we  have  material  for  studying  the  end-results  of  Young's  method,  which  is 
probably  the  best.  The  special  points  are  the  use  of  his  tractor,  and  the  preserva- 
tion of  the  ejaculatory  ducts  and  mucous  membrane  of  the  base  of  the  bladder. 


Mortality  of  Prostatectomy. 


Operation  and  Reporter 

Cases 

Died 

Mortality 

per  cent 

Freyer    ----- 

1000 

55 

5-5 

Thomson  Walker 

over  100 

— 

5 

c   J,     J,   t  ■    J  St.    Thomas's    Hospital,    1906-1910 
Suprapubic  -i  p^^^    London    hospitals,    i?o6-i9io 

69 

14 

20-3 

76 

16 

21 

Two    Bristol    hospitals,   1906-1912 

68 

24 

35-3 

\  A  hospital  (Wade) 

164 

54 

35-4 

Perineal — Young           .            -            -            -            - 

450 

17 

3-8 

The  mortality-rate  in  450  cases  was  17,  that  is,  3-8  per  cent  ;  there  were  128 
consecutive  operations  without  a  fatality.  Some  of  the  deaths  might  have  been 
prevented  by  more  careful  washing  out  of  the  bladder  beforehand. 

The  patients  get  about  quicker  than  after  the  suprapubic  operation,  more  than 
half  going  home  in  a  month. 


End-results  of  Prostatectomy. 


Operation  and  Eeporter 

§  0 

Cured 

Per 

sl 

il 

3  0 
30 

0 

^  a 

'^0 

W" 

cfl3 
a 

^1 

h 

asi 
3 

( Thomson  Walker 

112 

99 

80 

1 

0 

2 

6 

2 

2 

Suprapubic'^  St.  Thomas's  Hospital 

26 

20 

77 

0 

.3 

0 

i 

0 

1  Two  Bristol  hospitals 

32 

24 

75 

u 

3 

i 

0 

Perineal — Young 

403 

361? 

89 

0 

3 

12 

? 

27* 

0 

*  Open  .S  months  after  operation. 

The  end-results  were  followed  up  by  Young  in  403  cases — for  at  least  six  months 
in  all  but  26.  Of  these,  79  died  of  various  intercurrent  affections,  and  324 
survived  until  the  report. 

All  but  12  can  hold  water  for  three  hours  or  more  by  day  ;  about  a  quarter 
can  go  all  night,  but  most  have  to  rise  once  or  twice.     Although  70  per  cent 


412 


INDEX     OF     PROGNOSIS 


required  the  catheter  before  operation,  only  4  patients  were  still  wholly  dependent 
on  it,  and  8  more  had  some  partial  obstruction.  In  all  the  rest  there  was  a 
perfect  result  with  regard  to  micturition.  None  had  incontinence  night  and 
day  ;  3  only  by  day.  All  the  79  patients  who  died  did  well  as  far  as  urinary 
troubles  were  concerned,  except  2  who  are  included  in  this  summary.  The 
principal  drawback  of  the  perineal  route  is  persistence  of  the  fistula  ;  in  27  of 
Young's  cases  it  was  open  three  months  after  operation,  but  it  is  not  stated  in 
how  many  of  these  it  remained  open  permanently.  Some  other  advocates  of  the 
perineal  operation  report  3  to  6  per  cent  of  cases  of  persistent  fistula,  and  2  to  4 
per  cent  of  cases  of  recto-vesical  or  recto-urethral  fistula. 

Sexual  Power  (Erections)  Lost  after  Prostatectomy. 


Operation  and  Eeporter 

Cases 

Lost 
per  cent 

Suprapubic — ^Thomson  Walker  - 
Perineal — Young 

133 

12-5 
25 

The  sex-functions  were  retained  in  59  per  cent  of  133  cases  in  which  they  were 
normal  before  operation,  and  75  per  cent  still  obtained  erections. 

In  Young's  hands  the  perineal  operation  certainly  gives  better  results,  both 
immediately  and  remotely,  than  suprapubic  enucleation,  but  it  is  doubtful  if 
this  would  be  the  universal  experience.  It  is  better  perhaps  for  small  hard 
prostates,  but  Freyer's  method  will  still  hold  a  place  for  large  glands  that  shell 
out  easily. 

Bottini's  Operation  and  Young's  Bar -punch  Operation.  These  are  indicated 
in  cases  where  the  prostate  is  not  enlarged,  but  a  median  bar  obstructs  the 
urethra.  Young  reports  67  cases  treated  by  his  punch  without  a  death  ;  4  of 
these  were  failures,  and  63  gave  good  or  perfect  results. 

References. — Freyer,  Brit.  Med.  Jour.  1912,  ii,  868  ;  Thomson  Walker,  Clin.  Jour. 
1912,  xl,  261  ;  Page,  St.  Thomas's  Hosp.  Rep.  1910,  135  ;  Young,  Surg.  Gyn.  and 
Obst.  1911,  xiii,  269  ;  Young,  Keen's  Surgery,  vol.  vi,  670  ;  Wade,  Ann.  Surg.  1914, 
lix,  321.  A.  Rendle  Short. 

PROSTATIC  CALCULI. — These  are  not  very  often  met  with,  and,  of  course, 
require  removal.  Incontinence  of  urine  is  apt  to  follow  the  operation.  In  a 
case  under  Mr.  Morton's  care,  seen  by  the  writer,  they  returned  again  and  again 
after  repeated  removals.  A.  Rendle  Short. 

PSOAS  ABSCESS. — We  shall  confine  our  remarks  under  this  heading  to 
tuberculous  abscesses  arising,  in  the  great  majority  of  cases,  from  caries  of  the 
spine. 

The  material  available  for  coming  to  a  sound  conclusion  as  to  the  prognosis 
of  this  disease  is  very  scanty.  The  condition  is  rather  uncommon,  so  that  no 
one  surgeon  is  able  to  present  a  record  of  a  long  series  of  personally-observed 
cases.  We  shall  here  base  our  study  upon  the  not  very  recent  figures  of  Lovett, 
relating  to  54  patients  under  fourteen  years  of  age  treated  at  the  Boston  Chil- 
dren's Hospital,  and  upon  the  notes  of  56  cases  treated  at  the  Royal  Infirmary 
and  General  Hospital,  Bristol. 

The  great  majority  of  the  cases  were,  of  course,  operated  on.  Nevertheless, 
recovery   apart  from  operation  is  not  impossible,   given  rest  and  favourable 


PSOAS    ABSCESS 


413 


conditions.  Of  5  children  not  operated  on  at  Boston,  2  were  healed  ;  and  2 
probable  psoas  abscess  cases  at  one  of  the  Bristol  hospitals,  treated  by  rest, 
have  made  an  excellent  recovery.  Such  a  happy  issue  must  be  regarded  as 
exceptional  ;  usually  the  abscess  will  burst  and  become  infected  wdth  the 
organisms  of  suppuration,  which  of  course  makes  the  outlook  much  less  hopeful. 
At  the  Boston  Children's  Hospital,  the  routine  treatment  was  opening  and 
draining  by  a  tube  or  gauze.  More  modern  practice  would  prefer,  in  favourable 
cases,  to  evacuate  the  pus  and  sew  up  again  ;  and  the  results  might  have  been 
better  if  this  course  had  been  adopted.  Of  the  49  patients  operated  on,  none 
died  within  a  month  ;  6  were  lost  sight  of.  Of  the  43  followed  up  for  periods 
from,  one  to  ten  years,  17  died,  and  26  were  still  alive.  The  fatal  result  usually 
occurred  more  than  a  year  after  the  operation.  Of  the  26  survivors,  12  were 
cured,  10  much  improved,  but  still  suffering  from  sinuses  or  pain  in  the  back, 
and  4  were  little  or  no  better.  These  results,  and  those  of  the  Bristol  cases,  are 
set  out  in  the  table  subjoined. 


Results  of  Operation  for  Psoas  Abscess. 


Cases 

operated 

on 

Died 
within  a 
month 

Cases 
followed 

Cured 

or  nearly 

cured 

Much 
improved 

Un- 
changed 

Died 
since 

Boston  Children's  Hospital 
Two  hospitals,  Bristol 

49 
54 

0 

2 

43 

37* 

12 

17 

10 
3 

4 

4 

17 
13 

Total 

103 

2 

80 

29 

(or  36 
percent) 

13 

(or  16 
percent) 

8 

(or  10 

percent) 

30 

(or  37  5 
per  cent) 

*  11  cases  under  sixteen  years  ol  age,  26  over  sixteen. 

The  Bristol  cases  were  followed  for  periods  from  eighteen  months  to  twelve 
years  (very  few  under  two  years).  The  infected  cases  were  usually  drained,  and 
the  purely  tuberculous  abscesses  evacuated,  scraped,  and  closed.  The  results 
are  about  the  same  as  the  American  ones.  It  will  be  seen,  combining  the  figures, 
that  the  immediate  mortality  is  low,  about  2  per  cent  ;  that,  of  80  cases,  about 
a  third  are  cured  or  show  only  a  trifling  sinus,  a  third  have  died  since,  and  the 
remaining  third  are  either  improved  or  in  statu  quo,  the  wounds  remaining  open 
and  the  back  still  painful.  Contrary  to  expectation,  the  results  in  patients  over 
sixteen  were  very  decidedly  better  than  in  children  ;  of  the  former  group,  13 
out  of  23  did  well.  The  figures  are,  however,  too  small  to  be  reliable  on  this 
point. 

In  fatal  cases,  death  usually  takes  place  after  many  months  or  years  of 
invalidism ;  albuminoid  disease,  chronic  suppuration  and  exhaustion,  and 
tuberculous  meningitis  figuring  largely  in  the  final  issue.  The  average  time  in 
II  Bristol  cases  was  between  two  and  three  years. 

With  reference  to  the  prognosis  in  individual  cases,  the  outlook  is  much  graver 
if  secondary  infection  with  cocci  takes  place.  Lovett  shows  that  fever  is  of  bad 
omen  ;  thus,  of  10  febrile  cases,  3  lived,  7  died,  mortality  70  per  cent  ;  of  30 
afebrile  cases,  20  lived,  10  died,  mortality  33  per  cent. 

The  development  of  a  faecal  fistula  is  extremely  grave. 

With  reference  to  the  mode  of  operation,  Lovett  gives  evidence  which  tells 
against  the  practice  of  opening  both  in  the  groin  and  the  lumbar  region  ;  but 
it  must  be  borne  in  mind  that  the  double  incision  was  probably  adopted  for 
the  larger  abscesses.     His  table  is  as  follows  : — 


414 


INDEX     OF     PROGNOSIS 


Results  of  Different  Operations  (Lovett). 


Iliac  opening 

Lumbar  opening 

Iliac  and  lumbar  opening 

Gluteal  opening 


He  believes  that  a  better  result  is  obtained  if  the  patient  is  kept  sitting  or 
standing  after  operation,  to  promote  drainage. 

We  may  conclude,  therefore,  that  of  cases 
recover  more  or  less  completely,  a  third  die,  and 
and  some  go  on  for  years  in  a  wretched  state. 
fatal  cases  is  two  to  three  years.     According  to 
to  generalize  from),  it  would  appear  that  adults 
doubtful. 

Reference. — Lovett,  Boston  Med.  and  Surg.  Jour.  1901,  cxliv,  463.       ^.  Rendle  Short. 


of  psoas  abscess,   about  a  third 

,  of  the  remainder,  some  improve. 

The  average  duration  of  life  m 

the  figures  given  here  (too  small 

do  better  than  children  ;   this  is 


PSORIASIS. — We  have  to  consider  (i)  The  immediate  prognosis  ;  and  (2)  The 
liability  to  recurrence. 

1.  Immediate  Prognosis. — This  will  depend  upon  whether  the  patient  can  or 
cannot  give  himself  up  entirely  to  treatment.  The  ambulatory  treatment  of  an 
extensive  psoriasis  is  most  unsatisfactory,  and  the  patient  may  not  be  free  from 
the  eruption  for  years  ;  but  in  a  long-standing  case,  the  patient  may,  perhaps 
not  unwisely,  object  to  lying  up  for  the  removal  of  an  eruption  which  does  not 
trouble  him,  and  which  he  knows  by  experience  wiU  certainly  recur.  If  the 
sufferer  from  psoriasis  can  give  himself  up  to  treatment,  and  will  submit  to 
chrysarobin,  the  eruption  can  in  many  cases  be  removed  in  three  or  four  weeks. 
A  longer  time  \vill  usually  be  necessary  if  the  scalp  is  badly  involved,  as  chrys- 
arobin cannot  be  used  in  this  region.  No  other  remedy  is  so  rapid  in  its  action  ; 
if  the  drug  be  objected  to — and  it  has  many  drawbacks — a  longer  time  must  be 
allowed  for  treatment.  The  drugs  next  in  efficiency  are  the  tars,  oil  of  cade, 
pyrogallol,  and  the  derivative  of  the  latter,  eugallol. 

The  X  rays  have  been  used  extensively  in  psoriasis,  and  if  carefully  applied  to 
limited  areas  they  are  remarkably  efficient.  I  have  seen  cases  in  which  the 
periods  of  intermission  have  certainly  been  lengthened  by  the  ;ir-ray  treatment. 

As  regards  the  value  of  internal  treatment,  the  writer  cannot  say  that  he  has 
been  greatly  impressed  by  any  measure.  Arsenic,  given  either  by  the  mouth 
or,  probably  more  effectively,  by  injection,  is  certainly  of  some  value.  Hutchinson 
stated  that  he  had  cured  cases  hy  arsenic  alone  ;  and  the  writer  knows  cases  in 
which  its  timely  use,  together  with  simple  alkaline  baths,  cuts  short  an  attack. 

2.  Liability  to  Recurrence. — It  is  impossible  to  give  a  hopeful  prognosis  as 
regards  recurrences  in  psoriasis.  In  some  cases,  the  patient  may  be  free  for 
several  months,  or  a  year  or  so  ;  in  others,  the  intervals  last  for  a  few  Aveeks  only. 
Recurrence  sooner  or  later  is  the  rule,  and  nothing  that  we  know  at  present  can 
prevent  it.  The  patients  are  often  in  the  best  of  health,  and  in  some  instances 
they  only  lose  their  eruption  when  they  are  out  of  condition.  Relapses  are  less 
common  where  the  scalp  can  be  kept  free  from  disease,  and  the  eruption  is 
less  liable  to  recur  if  completely  removed  by  treatment ;  but  it  is  at  present 
impossible  to  speak  more  favourably.  /.  H.  Sequeira. 


PUERPERAL     SEPSIS 


415 


PUERPERAL  MANIA.— (5ee  Mental  Diseases.) 

PUERPERAL  SEPSIS. — In  puerperal  infections,  the  clinical  manifestations 
are  of  immense  importance  in  coming  to  a  decision  as  to  the  prognosis  in  indi- 
vidual cases.  With  regard  to  the  results  of  treatment,  so  much  variety  exists 
in  the  classification  of  cases,  that  it  is  difficult  to  compare  the  results  of 
different  reporters.  Thus,  while  for  some  American  and  English  authors  the 
mortality  is  lowered  by  half  when  vaccines  are  used,  other  writers,  especially 
Continental  authorities,  absolutely  ignoring  vaccine  therapy,  can  show  very 
similar  results.  The  truth  would  appear  to  be  that  there  is  an  average 
mortality-figure  for  each  group  of  puerperal  sepsis,  and  a  lower  mortality- 
figure  where  appropriate  treament  is  applied  in  each  case. 

The  last  few  years  have  seen  an  interest  aroused  in  the  question  of  thrombo- 
phlebitis and  its  surgical  treatment — with  results  which  are  not  at  first  sight 
encouraging,  but  may  readily  be  improved  upon. 

We  give  some  figures  relating  to  puerperal  infections  in  general,  compiled  in 
large  measure  from  those  quoted  by  Jeannin.-  The  death-rate  from  puerperal 
infection  in  all  labours  is  given  as  0-25  to  0-3  per  cent,  and  the  mortality  of 
puerperal  sepsis  represents  about  10  per  cent  of  all  cases,  including,  of  course, 
very  many  mild  cases.  If  only  the  more  serious  cases  of  puerperal  infection 
are  considered,  the  death-rate  is  at  least  30  per  cent. 

The  following  table  shows  the  relative  proportion  of  the  different  forms_of 
fatal  infections,  with  the  respective  death-rate. 

Table  Showing    the  Relative  Proportion  of  the    Different   Forms   of 
Fatal   Infections,  with  the  Respective  Death-rate. 


True  septicaemia       -.--.. 
General  peritonitis  .         .         _         .         . 

Pycemia  ....... 

Sloughing  endometritis  (saprasmia)  and  abscess 
Pneumonia  and  pleurisy  -         .         .  . 


40 
20 
15 
15 


Mortality 
per  cent 


95 
85 

72 
75 


A  rough  indication  of  the  prognosis  is  also  to  be  gained  by  a  knowledge  of 
the  infecting  organism  ;  streptococcal  organisms  are  obtained  from  the  uterus 
in  50  to  75  per  cent  of  all  cases  ;  they  are  the  most  to  be  feared— streptococcal 
cases  are  much  more  generally  fatal  than  those  due  to  any  other  organism. 
Staphylococcal  infections  seldom  give  rise  to  a  septicaemia,  but  commonly 
enter  into  local  lesions.  B.  coli  infections  are  comparatively  rare,  but  are 
said  to  be  dangerous  on  account  of  their  action  on  the  liver.  Gonococcal 
infections  most  frequently  end  in  tubal  disease  and  adhesions,  which  engender 
sterility  ;    it  is  seldom  that  they  prove  directly  fatal. 

It  has  been  noted  that  infections  which  have  taken  on  an  epidemic  form  are 
as  a  rule  much  more  virulent  than  the  average  run  of  sporadic  cases.  The 
explanation  is  to  be  found  in  an  acquired  virulence  during  the  passage  through 
the  human  body. 

Prognosis  from  the  Clinical  Standpoint. — It  is  a  good  thing  to  have  the  follow- 
ing rule  before  one  when  investigating  a  case  of  puerperal  sepsis  :  The 
gravity  of  an  infection  is  in  inverse  ratio  to  the  intensity  of  the  local  reaction  ; 
that  is  to  say,  where  there  is  nothing  found  to  account  for  the  symptoms,  the 


41 6  INDEX    OF    PROGNOSIS 

clinician  will  be  guarded  in  his  statements.  The  following  factors  are  of  varying 
importance. 

The  condition  of  the  patient,  especially  as  regards  preceding  obstetrical  opera- 
tions which  have  resulted  in  extensive  bruising  or  the  production  of  unclean 
wounds,  may  indicate  a  lowered  power  of  resistance.  Cases  of  albuminuria,  of 
eclampsia,  and  of  severe  haemorrhage  come  under  the  same  category,  and 
provide  a  large  proportion  of  cases  of  puerperal  infection  ending  fatally. 

In  comparing  post-abortion  with  post-partum  cases,  it  is  found  that  the  latter 
are,  generally  speaking,  much  less  favourable.  An  exception  is  to  be  made 
respecting  the  cases  subsequent  to  efforts  at  criminal  abortion,  in  which  the 
mortality  easily  reaches  5  per  cent. 

As  a  general  rule,  the  death-rate  is  higher  in  cases  (with  declared  puerperal 
sepsis)  transferred  to  institutions  than  in  cases  occurring  within  an  institution. 

The  date  of  onset  of  the  fever  has  an  important  significance.  An  infection 
which  is  evident  within  24  to  36  hours  after  labour  will  cause  anxiety  from  the 
outset,  while  cases  occurring  after  the  sixth  day  will  almost  certainly  show 
only  local  lesions  of  a  suppurative  character. 

The  severity  of  the  general  symptoms  bears  a  direct  relation  to  the  gravity  of 
the  septic  infection.  Thus,  a  temperature  maintained  about  104°,  a  pulse  of 
no  to  120  per  minute  and  remaining  fast  in  spite  of  oscillations  in  the  tempera- 
ture-reading, with  a  dry  tongue  and  loss  of  sleep,  are  bad  signs. 

The  correspondence  between  the  pulse  and  temperature  curves  should  be 
noted,  as  in  bad  cases  the  pulse  is  constantly  higher  than  the  temperature  curve, 
and  does  not  fall  when  the  temperature  is  lowered.  A  slow  pulse,  irrespective 
of  the  temperature,  may  be  taken  as  a  good  sign.  In  the  worst  cases,  there  is 
incontinence  and  dyspnoea,  and  the  extremities  become  cold.  In  the  absence 
of  vomiting  or  diarrhoea,  and  while  the  appetite  remains  and  the  patient  receives 
nutrition,  there  is  always  hope  that  the  resistance  to  disease  will  be  effective. 

Albumin  in  the  urine  and  a  diminution  in  quantity  of  the  latter  must  be 
taken    as  unfavourable. 

Jaundice  is  seen  in  cases  of  general  peritonitis,  and  indicates  wide  extension 
of  the  latter.  It  is  rare  in  such  cases  for  recovery  to  take  place.  The  condition 
must  not  be  mistaken  for  the  icteric  tinge  not  infrequently  seen  in  cases  of 
severe  septic  infection  with  high  temperature  ;  such  a  tinge  occurs  in  nearly 
all  fevers,  and  does  not  imply  a  serious  lesion  of  the  liver  tissues. 

The  blood  furnishes  information — in  the  first  place  bacteriologically,  as 
indicating  the  presence  or  absence  of  micro-organisms.  It  is  of  some  significance 
to  try  to  distinguish  the  true  septicaemias  from  the  occasional  bacterisemias. 
Thus,  a  culture  from  the  blood  within  an  hour  or  two  of  a  rigor  will  almost 
certainly  contain  bacteria  ;  but  the  same  patient's  blood  a  few  hours  later  may 
or  may  not  reveal  the  presence  of  organisms.  Such  a  discontinuous  bacteriaemia 
has  a  much  better  prognosis  than  the  continuous.  Again,  cultures  taken  when 
death  is  approaching  are  frequently  found  to  reveal  a  B.  coli  infection,  which 
is  probably  not  the  true  causal  agent.  The  presence  of  microbes  does  not 
necessarily  indicate  a  bad  prognosis,  as  Western,^  in  96  cases  of  puerperal  fever, 
found  definite  evidence  of  organisms  in  the  blood,  continuously  or  discontinuously, 
in  40  per  cent.  The  mortality  in  these  cases  was  :  in  the  group  treated  by 
vaccines,  32  per  cent;  in  the  group  treated  by  ordinary  methods,  55  per  cent. 
The  absence  of  microbes  in  the  blood  is,  of  course,  a  good  sign;  but  pneumonia, 
peritonitis,  or  some  other  complication,  may  cause  a  fatal  issue. 

In  the  second  place,  the  blood  has  been  examined  from  the  point  of  view  of 
leucocytosis.  In  the  milder  forms,  the  white  cells  should  range  round  20,000, 
and  the  polymorphs  should  not  exceed  90  per  cent  of  the  whole  ;    while  in  the 


PUERPERAL     SEPSIS  417 

severe  forms  the  leucocytosis  reaches  50,000,  the  polymorphs  represent  95  per 
cent  of  the  whole,  and  there  may  be  complete  disappearance  of  the  eosinophiles. 

Such  complications  as  endocarditis,  pericarditis,  suppurative  arthritis,  and 
pneumonia  are  ver\'  serious  indeed — while  with  the  development  of  thrombosis 
of  the  leg,  the  infection  often  subsides. 

The  conditions  prevailing  in  the  pelvis  help  materially  ;  when  the  lochia  are 
normal  and  inoffensive,  and  the  uterus  small  and  firm,  while  the  general 
symptoms  are  marked,  the  case  is  almost  certainly  one  of  septicsemic  nature  ; 
on  the  other  hand,  cases  ^vitll  a  large  bulky  uterus  and  offensive  discharge, 
or  a  local  swelling,  are  much  more  hopeful. 

The  Results  of  Treatment. — These  would  appear  to  be  more  a  matter  of 
recognizing  the  type  of  infection  and  applying  thereto  the  appropriate  treat- 
ment. The  difficulties  of  diagnosis  are  immense.  For  instance,  there  is  no 
doubt  that  operative  procedures  offer  the  best  chances  in  cases  of  thrombo- 
phlebitis, yet  clinicall}'  it  is  nearly  impossible  to  distinguish  these  cases  from 
the  true  septicaemias — in  fact,  the  two  frequently  co-exist. 

We  shall,  however,  consider  the  figures  given  by  different  authorities  for  the 
various  forms  of  treatment. 

The  conservative  treatment,  where  douching,  drugs,  and  local  applications 
are  used  according  to  the  clinical  manifestations,  show  a  \\dde  variation  in 
mortality,  depending  on  the  obser\^er. 

MoRT.\LiTY  IX  Cases  treated  by  Ordinary  Methods.  ^ 


Notified  cases    -  .         .         .         .         . 

Western^   (44  cases)  .  .         .         . 

Western  (Bacteriasmias)      .... 

Johnstone^  (Belvedere  Hospital) 
Jeannia^     ...... 

Stookes*  (Monsall  Hospital  in  1910 — 75  cases) 


per  cent 

58 

55 

87-5 

42 

30 

19-7 


Stookes^  included  all  cases  admitted,  and  it  is  not  stated  whether  vaccines 
were  used  or  not.  Great  variation  exists  in  deciding  what  constitutes  a  puerperal 
infection  :  thus,  Jeannin^  places  the  figure  at  10  per  cent  if  all  puerperal  infections 
are  included. 

Vaccines  have  recently  been  extensively  used  in  this  country  and  in  America. 
The  largest  series  was  treated  at  the  London  Hospital,  and  published  by 
Western.^  He  claims  that  it  is  possible  to  reduce  the  mortality  by  half  by 
using  autogenous  vaccines.  Thus,  in  56  cases  treated  with  vaccines,  the 
mortality  was  32  per  cent ;  in  44  treated  without  vaccines,  it  was  55  per  cent. 
Still  more  striking  are  his  figures  in  those  cases  where  there  were  organisms 
present  in  the  blood  at  the  time  of  culture  :  in  bacterismias  treated  without 
vaccines,  the  mortality'-  was  87-5  per  cent;  in  those  treated  with  vaccines,  it 
was  52  per  cent.  Western,  however,  was  of  opinion  that  vaccines  were  not  so 
useful  in  the  severe  type  of  cases  in  which  death  usually  ensued  within  ten 
days  of  the  onset.  He  also  found  stock  vaccines  unsatisfactory.  Polak,^  using 
polyvalent  vaccines,  had  only  6  deaths  in  28  cases  of  streptococcal  bacterisemia, 
i.e.,  21-4  per  cent  ;  and  in  12  staphylococcal  infections  only  i  died,  a  mortality 
of  8-3  per  cent. 

Antistreptococcal  or  antipnerperal  sera  have  now  received  an  extensive  trial. 
They  do  not  appear  to  have  been  very  successful.     Johnstone-  says  he  has 

27 


4i8  INDEX     OF     PROGNOSIS 

seen  no  benefit  from  their  use.  Jardine^  used  polyvalent  sera  in  25  cases,  with 
benefit  in  only  2.  Bonstedt,''  however,  believes  they  have  been  of  much  service 
in  a  series  of  26  cases  in  which  he  employed  them. 

Injections  of  a  2  per  cent  sterile  solution  of  magnesium  sulphate  have  recently 
been  used.  In  this  way  James  A.  Harrar^  treated  14  cases  of  severe  septicaemia 
— in  5  cases  streptococci  were  isolated  from  the  blood,  with  i  death  ;  while  in 
the  other  9  cases  streptococci  were  cultured  from  the  uterus,  and  again  i  died. 
He  finds  this  method  useless  in  thrombophlebitis,  pus  collections,  and  chronic 
pyaemias.     To  obtain  good  results  the  treatment  must  be  undertaken  early. 

The  operative  treatment  of  thrombophlebitis  still  shows  a  very  high  mortality. 
Jeannin,  Vanverts,  and  Paucot^  collected  82  cases  up  to  1912,  with  a  mortality 
of  59-8  per  cent.  But  it  must  be  remembered  that  this  list  includes  some  of 
the  first  operations,  and  also  many  hopeless  cases.  Thus,  in  some  cases  there 
was  thrombosis  of  pelvic  and  uterine  veins  of  both  sides,  of  ovarian,  and  even 
of  the  hypogastric  veins.  The  cases  operated  upon  within  the  last  year  or 
two  would  show  more  favourable  results.  On  the  other  hand,  it  appears  that 
thrombosis  of  the  veins  is  found  in  the  majority  of  puerperal  infections,  and 
in  less  than  one-third  it  constitutes  the  only  lesion  ;  of  these  latter,  it  appears 
that  the  thrombosed  vessel  is  capable  of  satisfactory  surgical  treatment  in  70 
per  cent. 

References. — ^Lancet,  igia.Feb.  10  ;  ^Jour.  Obst.  andGyn.  rgis,  June,  367;  ^Pratique 
de  VArt  de  V Accouchement,  1914,  3rd  edition,  vol.  i,  640  at  seq.  ;  *Joiir.  Obst.  and  Gyn. 
1913,  March,  178  ;  ^Jour.  Amer.  Med.  Assoc.  1911,  Nov.  25  ;  ^Jour.  Obst.  and  Gyn. 
1912,  June,  378  ;  ''Monats.  f.  Geb.  u.  Gyn.  xxiv,  Hft.  i,  46  ;  ^Amer.  Jour.  Obst.  1913, 
Nov. ;  ^Arch.  Mens.  d'Obst.  et  de  Gyn.  1912,  Nov.  Bryden  Glendining. 

PULMONARY  TUBERCULOSIS. — The  prognosis  in  pulmonary  tuberculosis 
in  an  individual  case  is  extremely  difficult,  so  much  so  that  it  has  been  said  that 
he  who  attempts  it  can  be  sure  of  one  thing  only,  and  that  is  that  he  will  be 
mistaken.  Patients  who  appear  to  be  doing  well,  and  in  whom  the  disease 
seems  to  be  almost  arrested,  may,  and  often  do,  suffer  a  relapse  brought  about 
by  fatigue,  intercurrent  illness,  or  other  cause,  or  may  die  from  haemoptysis, 
meningitis,  or  pneumothorax.  For  example,  a  doctor  who  had  recovered  from 
an  acute  attack  of  the  disease,  who  had  doubled  his  weight,  and  was  capable 
of  walking  fifteen  miles  with  no  rise  of  temperature,  as  the  result  of  sanatorium 
treatment,  suffered  a  severe  relapse  owing  to  an  afternoon's  enthusiastic  tobogan- 
ning.  This  laid  him  up  in  bed  for  five  months,  and  rendered  him  a  more  or 
less  permanent  invalid  during  the  remainder  of  his  life. 

On  the  other  hand,  every  physician  of  wide  experience  in  this  disease  comes 
across  numerous  instances  of  patients  whose  life  at  some  time  or  other  has  not 
appeared  likely  to  be  prolonged  for  more  than  a  few  months,  and  who  nevertheless 
make  a  surprisingly  good  recovery.  Three  examples  from  my  own  experience 
may  be  given. 

A  Frenchman  living  in  New  York,  who  was  apparently  dying,  was  anxious 
to  go  to  Paris  to  take  farewell  of  his  family,  and  consulted  a  number  of  physicians 
on  the  subject.  All  except  one  thought  he  would  die  on  the  voyage,  and  advised 
him  not  to  undertake  it.  He,  however,  went  to  Paris,  taking  a  coffin  with  him 
on  the  voyage.  He  improved  somewhat,  and  then  went  to  a  well-known 
sanatorium,  where  he  became  so  much  better  that  he  was  able  to  take  up  his 
work  again.  He  lived  an  adventurous  life  in  all  chmates,  and  often  faced 
conditions  which  would  have  tried  a  strong,  healthy  man.  When  he  consulted 
me  some  fifteen  years  later,  there  was  no  active  disease,  but  much  fibrosis, 
some  dry  excavation,  together  with  shortness  of  breath.  He  died  two  years 
afterwards  from  profuse  haemoptysis. 


PULMONARY     TUBERCULOSIS  419 

A  working  man  came  to  my  out-patient  room  at  the  Brompton  Hospital, 
apparently  in  the  last  stages  of  the  disease.  Both  lungs  were  extensively 
infiltrated,  with  signs  of  excavation  in  three  lobes,  a  large  laryngeal  ulcer  was 
present,  and  the  temperature  was  103°.  The  man  refused  to  go  to  an  infirmary, 
and  it  was  impossible  to  get  a  bed  for  him  in  a  home  for  the  dying.  A  philan- 
thropic lady  gave  the  necessary  funds  for  him  to  be  boarded  out  in  the  country. 
He  had  practically  no  medical  treatment,  but  when  I  saw  him  a  year  later,  all 
signs  of  active  disease  had  gone,  satisfactory  fibrosis  had  taken  place,  the 
laryngeal  ulcer  was  completely  healed,  and  his  general  condition  was  so 
satisfactory  that  he  was  sent  to  the  Frimley  Sanatorium,  where  he  reached  the 
highest  grade  of  labour.  He  continued  to  do  well  for  some  years,  although  he 
never  returned  to  his  occupation,  preferring  to  live  on  the  charity  of  the  lady 
who  had  befriended  him  when  he  was  thought  to  be  dying. 

A  doctor  who  had  just  qualified  was  found  to  be  in  an  early  stage  of  the  disease, 
and  led  an  open-air  life  for  two  or  more  years.  When  I  saw  him,  some  thirty 
years  afterwards,  he  was  capable  of  very  hard  work  ;  and  he  told  me  that  apart 
from  an  occasional  attack  of  fever  lasting  a  week  or  two,  he  had  been  able  to  cope 
single-handed  all  this  time  with  a  practice  which  was  so  arduous  that  although 
he  kept  four  horses  he  was  never  able  to  drive  a  pair.  The  whole  of  the  left  lung 
was  infiltrated,  and  there  was  an  unusually  large  cavity  in  the  lower  lobe.  This 
patient  died,  when  over  seventy,  from  cerebral  haemorrhage. 

These  cases  are  sufficient  to  show  the  folly  of  making  too  dogmatic  statements 
about  the  future  of  anyone  suffering  from  pulmonary  tuberculosis.  Nevertheless, 
certain  wide  general  statements  may  be  made  on  the  subject  of  prognosis.  In 
the  first  place,  pathological  investigations  show  that  the  defensive  forces  of  the 
body  are  capable  of  defeating  the  invading  tubercle  bacillus  with  extraordinary 
frequency,  and  that  many  persons  suffer  from  slight  degrees  of  pulmonary 
tuberculosis  and  recover  completely.  In  fact,  pathological  evidence  is  the 
strongest  we  have  to  demonstrate  the  curability  of  the  disease.  It  shows  us  that 
many  persons  contract  consumption,  and  yet  recover  without  their  condition 
being  diagnosed.  Clinical  evidence,  similarly,  shows  that  a  number  of  persons 
have  the  disease  in  such  a  slight  form  that  a  short  holiday,  or  a  few  months'  rest 
under  open-air  conditions,  brings  about  a  complete  restoration  to  health.  In  fact, 
it  is  probably  true  that  at  least  20  per  cent  of  the  cases  of  pulmonary  tuber- 
culosis in  which  a  clinical  diagnosis  can  be  made,  end  in  recovery  whatever 
the  treatment,  and  sometimes  in  spite  of  treatment.  In  other  instances,  the 
disease  has  obtained  a  firmer  hold,  and  more  prolonged  and  rigid  treatment  is 
required  to  enable  the  defensive  forces  of  the  body  to  gain  the  victory  ;  and 
in  yet  other  cases,  some  of  them  diagnosed  in  the  early  stages,  no  form  of 
treatment  appears  to  have  much,  if  any,  effect  in  arresting  the  activity  or  the 
progress  of  the  disease. 

These  differences  are  due  to  the  fact  that  in  this,  as  in  every  form  of  infec- 
tive disease,  we  have  a  constant  war  between  the  invading  micro-organisms 
and  what  may  be  termed  comprehensively  the  defensive  forces  of  the  body. 
The  latter  are  complicated  things,  and  upon  their  response  to  the  invading 
organisms  or  their  products  depends  the  question  of  recovery,  or  extension  of 
the  disease  and  eventual  death.  The  questions  of  recovery,  partial  recovery, 
and  arrest,  or  gradual  extension  of  the  tuberculous  process,  depend  upon  the 
ratio  of  the  virulence  of  the  bacilli  and  the  specific  resistance  of  the  defensive 
forces  of  the  body  under  the  particular  conditions  of  the  individual  case.  If 
there  is  no  response  on  the  part  of  the  defensive  forces,  or  if  the  response  is  such 
that  the  toxic  effect  of  the  bacilli  or  their  products  is  not  neutralized,  the  inllam- 
matory  process  continues,  and  the  disease  extends. 


420  INDEX     OF     PROGNOSIS 

In  prognosis,  therefore,  we  are  faced  with  the  problem.  How  will  the  defensive 
forces  respond  to  the  attack  ?  If  the  bacilli  are  virulent  and  the  patient's 
strength  is  undermined,  the  outlook,  even  with  opportunities  for  satisfactory- 
methods  of  treatment,  commenced  at  an  early  stage  of  the  disease,  is  bad.  If 
the  bacilli  and  their  products  elicit  an  effective  response,  and  the  conditions  for 
treatment  are  satisfactory,  the  outlook  is  far  more  favourable. 

Factors  influencing  thie  Prognosis. —  From  the  above  it  will  be  clear  that  in  the 
prognosis  of  this  disease  the  m.ost  important  factor  to  be  taken  into  account 
is  the  response  of  the  defensive  forces.  If  the  patient  suffers  from  toxic  effects 
such  as  mialaise,  loss  of  appetite  and  of  weight,  fever  to  99°  or  more  when  at  rest, 
we  know  that  the  response  is  ineffective,  and  that  the  disease,  being  active,  is 
extending.  On  the  other  hand,  if  the  patient  loses  his  sense  of  fatigue,  gains 
weight,  has  an  afebrile  temperature,  and  has  less  signs  of  local  irritation,  such 
as  diminution  in  the  amount  of  expectoration,  we  know  that  the  response  is 
effective. 

The  above  reasoning  helps  us  to  understand  how  different  types  of  the  disease 
are  associated  with  a  varying  prognosis,  and  how  the  prognosis  depends  upon 
the  varying  conditions  of  hfe,  environment,  and  constitution  of  the  individual 
patients.  In  estabhshed  miliary  tuberculosis  the  outlook  is  hopeless  ;  in  acute 
caseous  tuberculosis,  associated  with  fever  and  other  signs  of  toxaemia  for  several 
months,  it  is  always  grave,  as  it  is  in  the  comparatively  rare  form  of  pneumonic 
tuberculosis  in  adults.  In  the  pneumonic  form  in  children,  the  portion  of  lung 
affected  not  infrequently  breaks  down,  a  cavity'  is  rapidly  formed,  the  caseous 
matter  is  expectorated,  the  disease  ceases  to  extend,  and  the  patient  recovers. 

Again,  the  state  of  the  patient's  previous  health  has  a  marked  effect  upon  his 
capacity  to  respond.  Thus,  when  pulmonary  tuberculosis  is  grafted  on  such 
diseases  as  chronic  Bright's  disease,  diabetes,  or  cancer,  it  is  incapable  of  cure, 
and  only  accelerates  the  end.  Similarly,  the  development  of  such  complications 
as  chronic  albuminuria  or  glycosuria  in  a  case  of  pulmonary  tuberculosis  is  of  the 
gravest  significance.  As  a  further  example  of  this  point,  it  may  be  mentioned 
that  the  death-rate  from  pulmonary  tuberculosis  in  lunatics  approaches  25  per 
cent.  A  chronic  alcoholic  rarely  recovers  from  consumption.  Syphilis  often 
leads  to  the  subsequent  development  of  tuberculosis,  and  is  a  grave  complication 
of  the  disease  :  in  many  instances  in  which  it  is  difficult  to  explain  the  unsatis- 
factory progress  of  a  case,  it  will  be  found  that  there  is  a  history  of  previous 
syphilis,  ^\^th  the  persistence  of  a  positive  Wassermann  test.  Further,  a 
consumptive  who  is  also  an  alcoholic  and  a  syphilitic  may  be  regarded  as  having 
practically  no  chance  of  recovery. 

The  earlier  the  disease  is  diagnosed,  and  the  patient  brought  under  efficient 
treatment,  the  better  is  the  outlook  ;  but  even  if  the  diagnosis  is  made  in  the  earliest 
stages,  and  efficient  treatment  is  immediately  undertaken,  at  least  10  to  15  per 
cent  of  the  cases  fail  to  make  an  efficient  response,  and  a  fatal  ending  is  brought 
about  in  from  one  to  three  years.  On  the  other  hand,  the  mere  fact  that  the 
disease  is  in  an  advanced  stage  when  discovered  does  not  preclude  recovery. 
In  a  number  of  instances  in  which  the  disease  is  advanced  there  has  been  very 
good  resistance,  and  but  little  is  required  to  make  the  defensive  forces  victorious. 
Thus  a  working  man  who  has  continued  his  work  under  bad  conditions  whilst 
the  disease  has  made  slow  but  considerable  progress,  and  until  he  is  forced 
to  seek  advice,  will  often  do  well  when  placed  under  more  helpful  conditions. 

The  character  of  the  onset,  apart  from  the  forms  of  the  disease  already  discussed, 
has  an  effect  on  the  prognosis.  When  the  first  sj^mptom  iS  haemoptysis,  patients 
often  do  very  well.  This  is  largely  accounted  for  by  the  fact  that  this  symptom 
alarms  the  patient  and  impresses  him  with  the  necessity  for  treatment  at  a  time 


PULMONARY     TUBERCULOSIS  421 


when  there  is  only  a  sHght  amount  of  infiltration.  When  the  onset  is  pleuritic, 
and  efficient  treatment  is  commenced  at  once,  the  outlook  is  usually  favourable. 

Family  characteristics  have  some  bearing  on  this  question.  If  two  or  more 
members  have  died  from  the  disease  without  any  real  response  having  been  made 
to  the  infection,  it  is  a  fair  deduction  that  the  resistance  of  the  family  is  poor  ; 
and  if  another  member  of  the  family  contracts  the  disease,  the  outlook  as  a  rule 
is  not  satisfactory. 

Apart  from  the  above  considerations,  the  most  important  factors  are — the 
character  of  the  patient  ;  his  facilities  for  treatment  ;  and  the  conditions  he 
has  to  face  after  the  disease  has  become  arrested. 

Everything  depends  on  the  character  of  the  patient.  This  has  been  expressed 
more  forcibly  by  the  statement  that  in  this  disease  it  is  "  impossible  to  cure  a 
fool."  The  patient  must  depend  on  himself  ;  his  doctor  can  direct  him,  but 
unless  he  is  prepared  to  devote  himself  whole-heartedly  to  the  details  of  treatment 
until  the  arrest  of  the  disease  has  continued  for  at  least  two  years  after  the 
resumption  of  work,  his  chance  of  permanent  recovery  is  small. 

The  question  of  facilities  for  treatment  speaks  for  itself  ;  the  value  of  different 
forms  of  treatment  is  discussed  later. 

The  after-conditions  are  important.  It  is  often  said  that  treatment  of  this 
disease  is  a  failure,  because  so  many  relapses  take  place  when  it  appears  to 
have  been  arrested.  If  a  man  breaks  his  leg  by  tripping  over  orange  peel,  has 
it  firmly  united  by  proper  treatment,  and  subsequently  fractures  it  again  by 
once  more  slipping  on  orange  peel,  it  is  no  reflection  on  the  treatment  given.  If 
a  man  owing  to  bad  conditions  has  his  defence  so  undermined  that  he  contracts 
tuberculosis,  it  is  no  reflection  on  sanatorium  treatment  if,  after  the  disease  has 
undergone  arrest,  he  suffers  from  a  relapse  as  the  direct  result  of  returning  to 
precisely  the  same  conditions  as  those  under  which  the  disease  originated.  The 
essential  things  in  the  after-condition  are  the  avoidance  of  fatigue,  the  avoidance 
of  impure  air  (rather  than  the  necessity  of  making  a  fetish  of  open-air  conditions), 
and  the  opportunity  of  having  a  rest  at  once  if  slight  illness,  such  as  a  feverish 
cold,  or  symptoms  of  renewed  activity  of  the  disease,  occur.  Fatigue  is  the  usual 
cause  of  relapse,  and  in  many  instances  it  is  fatigue  produced  in  the  excitement 
of  sport. 

In  conclusion  of  this  part  of  the  subject,  we  may  say  that  if  the  disease  is  acute 
and  no  response  is  made,  death  may  take  place  in  three  months,  and  is  seldom 
delayed  much  beyond  two  years.  If  we  consider  the  cases  which  end  fatally 
in  the  consumption  hospitals. — and  most  of  these  cases  are  presumably  of  the 
more  acute  type — the  majority  (to  the  extent  of  80  per  cent)  have  a  duration 
of  less  than  three  years,  and  only  about  6  per  cent  have  a  duration  of  over  four 
years. 

This  type  of  the  disease  may  be  recognized  by  certain  clinical  signs,  as  these 
are  an  index  to  the  activity  of  the  disease.  So  long  as  fever  continues,  the  disease 
is  active.  If  fever  is  not  reduced  by  absolute  rest,  and  continues  for  some 
months,  the  outlook  is  always  extremely  grave.  Again,  if  slight  degrees  of 
exercise  always  produce  fever,  which  persists  in  spite  of  rest,  the  case  is  an 
unfavourable  one.  In  such  instances  the  production  of  rest  to  the  affected  lung, 
by  means  of  a  pneumothorax  induced  by  nitrogen  gas,  more  especially  when  this 
method  is  adopted  at  an  earlier  stage  than  is  usually  the  case  at  present,  may  do 
much  to  prolong  life  and,  in  a  certain  number  of  cases,  to  bring  about  permanent 
arrest. 

The  pulse,  like  the  temperature,  is  an  index  to  the  activity  of  the  disease,  and 
a  persistently  rapid  pulse-rate,  or  one  which  is  readily  increased  by  exertion, 
is  associated  with  an  unsatisfactory  prognosis.     A  sense  of  malaise  or  easy  fatigue 


422  ■  INDEX     OF     PROGNOSIS 

is  similarly  indicative  of  a  poor  response  on  the  part  of  the  patient's  defensive 
forces  ;  and  its  persistence  in  spite  of  treatment,  like  the  persistence  of  other 
signs  of  toxaemia,  such  as  loss  of  weight,  sweating,  etc.,  is  associated  with  a  bad 
prognosis. 

The  extent  or  character  of  the  physical  signs  are  of  little  assistance  in 
determining  the  activity  of  the  disease  ;  the  important  things  are  the  degree  of 
toxaemia  and  the  response  of  the  individual.  Increased  expectoration  and 
repeated  haemorrhage  usually  signify  that  the  patient's  chances  are  diminishing. 
The  persistent  presence  of  tubercle  bacilli  in  his  expectoration  is  often  associated 
with  failure  to  arrest  the  process,  but  bacilli  continue  to  be  present  in  the  sputum 
of  many  patients  who  retain  their  health  and  capacity  to  work  for  years.  In 
fact,  we  have  tubercle  carriers  just  as  we  have  typhoid  carriers.  The  presence 
of  secondary  organisms  in  the  sputum  is  not  necessarily  indicative  of  secondary 
infection,  and  many  patients  who  suffer  from  pulmonary  tuberculosis  associated 
with  bronchitis  live  long  and  useful  lives.  When  secondary  organisms  have 
invaded  the  tuberculous  tissue,  the  hope  of  recovery  is  greatly  diminished. 
A  further  point  is  that  a  persistent  diazo-reaction  of  the  urine  is  usually  associated 
with  an  unfavourable  prognosis. 

When  the  response  of  the  patient  is  more  satisfactory  than  it  is  in  the  acute 
cases,  but  still  inadequate,  or  when  the  response  is  adequate  but  the  conditions 
of  life  after  arrest  has  been  brought  about  are  unsatisfactory,  the  mean  duration 
of  life  probably  does  not  exceed  seven  to  eight  years.  Dr.  Stadler  showed  that 
of  670  male  and  female  patients  in  the  first  and  second  stages  of  the  disease  who 
were  not  treated  in  a  sanatorium,  54  per  cent  were  alive  at  the  end  of  six  years, 
and  44  per  cent  at  the  end  of  seven.  Of  these  670  patients,  only  40  per  cent  were 
capable  of  full  work  at  the  end  of  four  years  ;  whereas,  of  716  patients  treated 
at  the  Prussian  and  Hessian  Railway  Sanatorium,  60  per  cent  were  capable  of 
full  work  at  the  end  of  five  years. 

When  the  response  is  adequate  and  the  after-conditions  are  satisfactory,  the 
prognosis  is  good,  and  many  patients  are  capable  of  leading  very  active  lives  for 
many  years. 

Finally,  it  may  be  said  that  when  a  patient  who  has  suffered  from  pulmonary 
tuberculosis  feels  well  (probably,  in  sensible  patients,  the  most  reliable  guide  of 
all),  has  a  normal  temperature,  maintains  a  satisfactory  weight,  and  has  no 
return  or  increase  of  expectoration,  he  may  be  satisfied  as  to  his  condition,  no 
matter  what  physical  signs  may  be  present.  Conversely,  a  feeling  of  malaise, 
a  raised  temperature,  continued  loss  of  weight,  and  a  return  or  increase  of 
expectoration,  shows  the  presence  of  toxaemia  and  a  return  of  the  activity  of 
the  disease. 

Efficient  treatment  has  much  effect  on  the  future  of  the  large  proportion  of 
consumptives.  As  they  rely  on  their  defensive  forces  they  require  good  hygienic 
conditions — i.e.,  pure  air,  sufficient  food.  The  most  important  thing  in  their 
treatment  is  the  regulation  of  the  amount  of  exercise  in  such  a  way  that  the 
auto-inoculations  produced  stimulate  the  defensive  forces  of  the  body,  but  never 
paralyze  them.  This  is  the  principle  underlying  sanatorium  treatment.  The 
figures  given  below  suggest  that  climatic  necessities  have  been  overrated  in  the 
past ;  that  good  results  are  obtained  from  sanatorium  treatment  ;  and  that  these 
are  somewhat  improved  by  the  careful  use  of  tuberculin. 

Effects  of  Climate. — We  have  conclusive  evidence  that  pulmonary  tuberculosis 
is  capable  of  undergoing  complete  arrest  in  practically  any  kind  of  climate. 
Thus,  good  results  have  been  obtained  in  Russia  below  sea-level,  and  in  low-lying 
Holland.  Conversely,  the  death-rate  from  this  disease  among  Red  Indians 
in  the  Rocky  Mountains — one  of  the  finest  climates  in  the  world — is  stated  to  be 


PULMONARY     TUBERCULOSIS 


423 


25  per  cent  of  the  total  mortality.  This  is  doubtless  due  to  the  conditions  under 
which  the  Indians  live,  and  emphasizes  the  importance  of  the  immediate  environ- 
ment. The  theory  that  treatment  at  high  altitudes  is  far  superior  to  all  other 
climatic  or  hygienic  forms  of  treatment  is  not  supported  by  modern  observations. 
Perhaps  the  most  important  evidence  in  this  respect  is  that  of  Professor  Saugmann, 
who  has  contrasted  the  results  obtained  by  him  at  the  Vejlefjord  sanatorium 
in  Denmark  with  those  obtained  by  Turban  at  Davos.  The  Vejlefjord  sanatorium 
is  a  few  feet  above  the  sea  ;  Davos  has  an  altitude  of  5000  feet.  At  the  Danish 
sanatorium  the  average  stay  of  patients  was  176  days,  whereas  at  Davos  it  was 
222  days.  Again,  Turban's  patients  were  drawn  from  a  richer  class,  who  would 
be  in  a  better  position  to  look  after  themselves  when  they  had  left  the  sanatorium. 
In  spite  of  these  disadvantages,  the  results  obtained  by  Professor  Saugmann, 
given  below,  compare  favourably  with  those  obtained  by  Turban,  and  show 
conclusively  that  a  high  altitude  is  not  essential  to  the  successful  treatment  of 
consumption. 

Percentage  of  Patients  from  whose  Expectoration  Tubercle  Bacilli 
Disappeared  during  Treatment. 


stage 

Turbans 
sanatorium 

Vejlefjord 
sanatorium 

I 

II 

III 

74 
41 
11 

7i) 
65 
17 

Percentage  of  Patients  who  suffered  from  Fever  on   Admission 
BUT  became  Afebrile  during  Treatment. 


stage 

Turban's 

Vejlefjord 

sanatorium 

sanatorium 

I 

8.5 

83 

n 

80 

9() 

III 

44 

69 

Particulars    of    After-history    of    Patients    in    whose    Expectoration 
Tubercle  Bacilli  were  Present  during  stay  at    Sanatorium. 


STAGH     I 

Stage  II 

Stage  HI 

After-history 

Turban's 
sanatorium 

(after  1-7 
years) 

Vejlefjord 

sanatorium 

(after  ■2-10:i 

years) 

Turban's 

sanatorium 

(after  1-7 

years) 

Vejlefjord 

sanatorium 

(after  '210:; 

years) 

Turban's 

sanatorium 

(after  1-7 

years) 

Vejlefjord 

sanatorium 

(after  '2-10:; 

years) 

Able  to  work 
Unable  to  work  on  ac- 
count of  tuberculosis 
Died  from  tuberculosis 
Unknown 

per  cent 

94-7 
5-3 

per  cent 

91-4 

8-6 

per  cent 

54-0 

13-7 

2l>-6 

2'7 

per  cent 

71-3 

2-0 

25-7 
1-0 

per  cent 

16-8 

7-9 

72-2 

3-0 

per  cent 

24-7 

5-3 

67 -3 

1-2 

424 


INDEX    OF    PROGNOSIS 


Particulars  of  After-history  of  Patients  who  were 

ADMITTED    TO   SANATORIUM    WITH    FeVER. 


Stage  I 

STAGE  II 

STAGE  HI 

After -history- 

Turban's 

sanatorium 

(alter  1-7 

years) 

Vejleljord 

sanatorium 

(after  2-105 

years) 

Turban's 

sanatorium 

(after  4-7 

years) 

Vejlefjord 

sanatorium 

(after  2-10| 

years) 

Turban's 

sanatorium 

(after  1-7 

years) 

Vejlefjord 

sanatorium 

(after  210S 

years) 

Able  to  work 
Unable  to  work  on  ac- 
count of  tuberculosis 
Died  from  tuberculosis 
Unknown 

per  cent 

90 

5 
5 

per  cent 
100 

per  cent 

44-4 

14-4 

37-8 

3-3 

per  cent 

77-1 
22-9 

per  cent 

12-3 

7-4 

77-7 
2-5 

per  cent 

20-5 

3-9 

7R-6 

0-5 

Climate,  naturally,  cannot  be  ignored.  Much  better  results  are  obtained 
in  cold  or  temperate  climates  than  in  hot  or  tropical  ones.  Again,  results  are 
not  so  good  in  situations  which  are  damp,  or  wind-swept  and  exposed,  as  in 
dry  or  more  protected  situations.  A  change  of  climate  is  as  beneficial  to  the 
consumptive  as  to  others,  but  not  essential.  In  suitable  cases,  an  after-cure 
at  an  altitude  is  of  service  in  expanding  the  lungs. 

In  the  later  stages,  life  is  probably  prolonged  if  the  patient  is  able  to  avoid 
marked  climatic  changes,  and  to  reside  at  some  place  where  the  conditions  are 
suitable  for  the  particular  indications  of  the  case. 

Results  of  Sanatorium  Treatment.- — The  results  obtained  by  treatment  in  a 
sanatorium  vary,  as  might  be  anticipated,  according  to  the  condition  of  the 
patient  and  the  character  of  the  lesion  at  the  time  treatment  is  commenced. 
The  results  obtained  when  treatment  is  commenced  in  what  is  known  as  Turban's 
Stage  I*  are  far  better  and  more  lasting  than  those  obtained  when  treatment  is 
commenced  in  Stage  III.  Further,  the  results  are  more  lasting  according  to 
the  class  from  which  the  patient  is  drawn  and  according  to  the  character  of  his 
work  and  surroundings.  In  the  case  of  the  working  classes,  about  50  to  60  per 
cent  of  those  treated  in  Stage  I  may  be  expected  to  be  capable  of  work  five 
years  after  their  discharge  from  the  institution  ;  whilst  in  those  belonging 
to  the  upper  classes,  the  percentage  given  by  some  authorities  is  as  much  as 
80  to  90. 

It  is  unwise  to  rely  too  rauch  on  statistical  proof  under  present  conditions, 
for  it  is  difficult  to  compare  data  from  different  institutions,  owing  to  the  different 
methods  adopted  in  classification  and  treatment.  For  example,  in  some 
institutions  a  proportion  of  patients  receive  tuberculin  ;  in  others,  this  remedy 
is  not  used.  Certain  broad  conclusions,  however,  may  be  drawn,  and  the 
statistics  of  the  results  of  sanatorium  treatment  given  below  are  useful  for  that 
purpose.  These  are  largely  taken  from  the  excellent  chapter  on  this  subject  in 
Sir  R.  Douglas  Powell  and  Dr.  Hartley's  book  on  Diseases  of  the  Litngs  and 
PleurcB. 


*  Turban's  classification  may  be  described  as  follows:  — 

Stage  I. — A  slight  lesion  which  does  not  exceed  one  lobe  or  two  half  lobes. 

Stage  II. — A  slight  lesion  which  extends  further  than  in  Stage  I,  but  at  most  to  two  lobes  ;  or 
a  severe  lesion  which  extends,  at  most,  to  the  volume  of  one  lobe. 

Stage  III. — All  lesions  which  are  not  included  in  Stage  I  or  II. 

N.B. — A  slight  lesion  is  equivalent  to  infiltration:  a  severe  lesion  is  equivalent  to  consolidation 
and  excavation. 


PULMONARY     TUBERCULOSIS 


425 


I. — Showing  Results  of  Treatment  in  267  Cases  of  Early  Pulmonary 
Tuberculosis  (Stage  I,  Turban)  admitted  to  the  Stanhope 
Sanatorium  during  the  Years  1900-1908. 


Year  of 
admission 

Cases  discharged 

Condition  to  April  so,  1908 

Percentafie 
known  to  be 

Total 

Returned 
to  work 

At 
work 

At 
home 

Dead 

Lost 
sight  of 

Re- 
admitted^ 

at  work 

on  April  80th, 

1908 

1900-1901 

1901-1902 
1902-1903 
1903-1904 
1904-1905 
1905-1906 
1906-1907 
1907-1908 

14 
26 
20 
..    33 
35 
37 
51 
51 

14 
23 

21 
28 
30 
35 
45 
43 

7 
8 
7 

18 
16 
17 
29 
34 

1 

1 
1 

4 

5 

6 

15 

2 
10 

5 
6 
11 
7 
4 
1 

5 

7 
7 
8 
4 
7 
12 

1 

1 
1 

2 
1 

1 

50  0 
30-8 
35-0 
54-5 
45-7 
46-0 
56-9 
66-7 

Totals 

267 

239 

136 

33 

46 

50 

7 

50-0 

*  Not  included  in  the  total  cases  discharged  during  the  year. 


II.. —  Showing  Results  of  Sanatorium  Treatment  in  317  Cases  of 
Advanced  Pulmonary  Tuberculosis  (Stage  III,  Turban)  admitted 
to  the  Stanhope  Sanatorium  during  the  Years  1900-1908. 


Cases  discharged 

Condition  on  April  ,io,  1908 

Year  of 
admission 

known  to  be 

Total 

Returned 
to  work 

At 
work 

At 
home 

Dead 

12 

Lost 
sight  of 

Re- 
admitted* 

at  work 

on  AprQ  30th, 

1908 

1900-1901 

12 

3 

0-0 

1901-1902 

20 

8 

2 

— 

17 

1 

— 

10-0 

1902-1903 

31 

17 

<> 



26 

3 

1 

6'5 

1903-1904 

29 

11 

3 

— . 

26 

— 



10-3 

1904-1905 

37 

19 

6 

1 

27 

3 

0 

16-2 

1905-1906 

68 

25 

7 

8 

46 

7 

1 

10-3    , 

1906-1907 

62 

23 

10 

9 

41 

2 

3 

161 

1907-1908 

58 

24 

14 

32 

12 

— 

— 

24-1 

Totals 

317 

130 

44 

50 

207 

16 

7 

13-9 

*  Not  included  in  the  total  cases  discharged  for  the  year. 

These  statistics  of  Dr.  John  Gray,  which  are  confirmed  and  improved  upon 
by  other  Enghsh  observers  such  as  Dr.  Burton  Fanning,  show  the  capacity  for 
work  at  varying  intervals.  They  also  show  that  of  the  267  patients  treated  in 
an  early  stage,  46  were  known  to  be  dead  and  50  were  lost  sight  of  in  190S  ; 
whereas  of  the  317  patients  treated  in  an  advanced  stage,  207  were  known  to  be 
dead. 

The  statistics  of  the  German  State  Sanatoria,  although  not  strictly  comparable, 
as  they  refer  to  all  classes  of  cases,  show  that  44  per  cent  of  the  male  and  51  per 
cent  of  the  female  patients  were  capable  of  working  four  to  five  years  after  their 
discharge  from  the  institution. 


426 


INDEX     OF    PROGNOSIS 


III. — Showing  the  Immediate  and  After-results  in  Male  Patients 
Treated  in  German  Sanatoria  under  the  Provisions  of  the 
Invalidity  Insurance  Law  during  the  Years  1904  to  1908. 


Year    of 
treatment 

Number  of 
patients 

Immediate 

results, 
showing  per- 
centage 
capable  of 
woik  after 
leaving  the 
sanatorium 

After-results,  showing  the  percentage  of  patients  capable 

of  work  at  the  end  of  various  years  after  leaving  the 

institution. 

1904 

1905 

1906 

1907 

1908 

1904 
1905 
1906 
1907 
1908 

16,957 
19,085 
21,959 
22,258 
26,437 

79 
81 

82 
81 
81 

73 

61 

76 

53 
63 

77 

48 
54 
fio 

77 

44 
49 
55 
65 

77 

III^.. — Showing  the  Immediate  and  After-results  in  Female  Patients 
Treated  in  German  Sanatoria  under  the  Provisions  of  the 
Invalidity  Insurance  Law  during  the  Years  1904  to  1908. 


Year  of 

Number  of 
patients 

Immediate 
results, 
showing  per- 
centage 
capable  of 
■work  after 
leaving  the 
sanatorium 

After-results,  showing  the  percentage  of  patients  capable 

of  work  at  the  end  of  various  years  after  leaving 

the  institution. 

1904 

1905 

1906 

1907 

1908 

1904 
1905 
1906 
1907 
1908 

6,520 
7,536 
9.063 
9,816 
12,288 

81 
83 
85 
84 
86 

76 

66 
78 

59 

67 
81 

55 
60 
70 

80 

51 
55 
63 
6<) 

82 

Slightly  better  results  have  been  obtained  in  other  German  sanatoria.  Thus, 
in  the  case  of  the  Prussian  and  Hessian  Railway  Company  employes,  60  per  cent 
were  capable  of  full  work  five  years  after  leaving  the  sanatorium,  although 
a  considerable  proportion  of  the  cases  (26  per  cent  in  1908)  were  in  Turban's 
Stage  III. 


IV.- 


-Showing  the  Immediate  and  After-results  of  Sanatorium  Treatment 

AMONG      THE    EMPLOYES     OF     THE     PRUSSIAN     AND      HeSSIAN     RAILWAY 

Companies  during  the  Years  1904  to  1908. 


Figures  showing  the  percentage  of  patients  capable  of  full 

■work  at  the 

end  of  various  years  after  leaving  the  institution 

Year  of 

Number  of 
patients 

treatment 

1904 

1905 

1906 

1907 

1908 

1904 

716 

81-7 

74-6 

66-6 

63-0 

59-8 

1!)05 

810 



85  "3 

76-7 

71-8 

68-1 

1906 

1,180 

— 

— 

85-8 

70-0 

73-0 

1907 

955 

— 

— 

— 

81-0 

73-0 

1908 

1,152 

— 

82-5 

PULMONARY     TUBERCULOSIS 


427 


In  patients  belonging  to  the  upper  classes,  the  results  of  sanatorium  treatment 
show  that  in  the  early  cases  a  larger  percentage  are  capable  of  work  than  is  shown 
by  the  statistics  for  the  working  classes,  and  confirm  the  observation  that 
treatment  in  the  later  stages  is  seldom  accompanied  by  satisfactory  results  for 
any  length  of  time. 

Dr.  Noel  Bardswell  has  given  the  results  obtained  in  the  case  of  patients 
treated  by  him  at  the  Mundesley  Sanatorium  from  1901  to  1905,  as  observed 
to  the  year  1909. 

V. — Showing    Results    obtained    in    241    Male    and    Female    Patients 

BELONGING    TO    THE    UPPER    CLASSES  AT  THE  MUNDESLEY  SaNATOPvIUM, 

Norfolk,  during  the  Five  Years  1901  to  1905. 


All 

Cases   considered  toi 

^ether 

Tear 
ot  dis- 
charge 

Number 

dis- 
charged 

Number  known  to  be  well  or  alive  on  January  1st  of 
each  year  since  discharge 

Condition  ol  patients  on  January 

1902 

1903 

1904 

1905 

1906 

1907 

1908 

1909 

1901 
1902 

1903 
1904 

1905 

58  (5) 

53 

55  (2) 
34 

15 

215* 

49 

39 
48 

33 
39 
52 

27 
35 
43 
33 

26 
32 
36 
31 

13 

24 
31 
35 
29 

12 

22 
30 
34 

29 

9 

20 
26 
32 

28 

8 

Well           -    99(41-0)1-7.^ 
Alive         -     15  (  6-2)  (*'  " 
Died          -  101  (41-9)  ^ 
Died  in                          U9-9 
sanatorium  19  (  8-0)  J 
Lost  sight  of    7  (3-0) 

Total    241 

*  In  addition  to  these  215  cases,  7  patients  (.ig ares  in  brackets^  were  discharged,  but  have  since 
been  lost  sight  of,  and  19  died  in  the  sanatorium,  making  the  total  treated  241. 

Incipient    Cases. 


1901 

10  (2) 

10 

10 

10 

9 

9 

8 

7 

6 

Well            -  46  (74-0)  I  ^... 
Alive           -    1  (  1-6))  '^^ 

1902 

15 

— 

15 

14 

14 

14 

13 

13 

12 

1903 

18  (2) 

— 

— 

18 

16 

16 

15 

15 

15 

Died  (none  in 
sanatorium)  11  (17'C) 

1904 

11 

— 

— 

— 

11 

11 

11 

11 

11 

1905 

4 
58t 

4 

3 

3 

3 

Lost  sight  of   4  (  6-4) 
Total    62 

+  In  addition  to  these  58  cases,  4  patien^^s  (figures  in  brackets)  were  discharged,  but  have  been 
lost  sight  of,  making  the  total  treated  62. 


- 

Moderately    Advanced  Cases. 

1901 

24  (3) 

23 

17 

15 

12 

11 

11 

11 

11 

Well              -47(49-4U„.„ 
Alive             -  10(10-5/^-'"' 

1902 

19 

— 

19 

16 

15 

14 

14 

13 

12 

1903 

25 

— 

24 

21 

16 

16 

16 

15 

Died  (one  in 
sanatorium)  35  (36-8) 

1904 

16 

— 

— 

— 

J  6 

16 

lij 

15 

14 

1905 

7 

7 

7 

5 

5 

Lost  sight  of    3  (  31) 
Total      95 

X  In  addition  to  these  91  cases,  3  patients  (figures  in  brackets)  were  discharged,  but  have  since  been 
lost  sight  of,  and  one  died  in  the  sanatorum,  making  the  total  treated  95. 


428 


INDEX     OF     PROGNOSIS 


Far-advanced 

Cases. 

Year 

Number 

dis- 
charged 

Number  known  to  be  well  or  alive  on  January  1st  of 
each  year  since  discharge 

charge 

1902 

1903 

1904 

1905 

1906 

1907 

1908 

1909 

1,  1909  (percentage  in  brackets)- 

1901 
1902 
1903 

1901 
1905 

24 
19 
12 

7 
4 

66§ 

16 

12 
12 

8 

9 

10 

6 
6 
6 

6 

6 
4 
4 

4 

2 

5 
4 
4 

3 
2 

4 
4 
3 

3 

1 

3 
2 

2 

3 

WeU            -     6  (7-1)1 -(..Q 
Alive           -     4(4-7)i'^^^ 
Dieci(i8  in 
sanatorium)  74  (88 '0) 

Lost  sight  of  - 

Total     84 

§  In  addition  to  these  66  cases,  i8  patients  died  in  the  sanatorium,  making  the  total  treated  84. 

Careful  observations  in  the  same  direction  have  been  made  by  Dr.  Lawrason 
Brown  and  the  late  Mr.  E.  G.  Pope  on  the  results  obtained  in  2,222  patients 
admitted  in  all  stages  of  the  disease,  who  were  treated  at  the  Adirondack 
Cottage  Sanatorium  in  New  York  State.  The  immediate  results  gave  a  per- 
centage of  56  apparently  cured,  and  32  arrested,  out  of  620  early  cases. 

VI. — Showing  the  CoNnixioN  on  Discharge  of  2,222  Patients  admitted  to 
THE  Adirondack  Cottage  Sanatorium,    New   York  State,   U.S.A. 


Number  of 
patients 

Condition  on  Discharge 

Condition  on  admission 

.Apparently 

cured 

(per  cent) 

Disease 
arrested 
(per  cent) 

Disease 

active 

(per  centl 

Died  in  the 
sanatorium 
(per  cent) 

Incipient  Cases 
Moderately  Advanced 
Far  Advanced 

620 

1,329 

273 

56 

12 

0 

32 
46 
16 

11 

40 

78 

003 
200 
6  00 

The  after-results  of  these  cases,  calculated  in  terms  of  1000,  showed  : — 

1.  That  750  patients  out  of  1000  discharged  as  apparently  cured  survived  at 
the  end  of  15  years,  as  against  850  out  of  1000  of  the  general  population. 

2.  That  the  expectancy  of  life  in  those  discharged  with  arrested  disease  (which 
includes  32  per  cent  of  the  incipient  cases,  46  per  cent  of  the  moderately  advanced, 
and  16  per  cent  of  far  advanced)  was  between  seven  and  eight  years. 

Results  of  Tuberculin  Treatment.— It  is  difficult  to  prove  by  any  method  other 
than  the  personal  supervision  of  a  large  series  of  cases,  that  tuberculin  is  of  the 
value  in  pulmonary  tuberculosis  that  most  authorities  on  this  disease  consider  it. 
Statistics  are  open  to  many  fallacies  when  used  for  such  a  purpose  ;  but  it  is 
recognized — much  more  strongly  by  physicians  in  Germany,  Switzerland,  and 
America  than  by  most  physicians  in  England,  it  is  fair  to  add— that  tuberculin 
is  of  considerable  value  both  as  regards  the  immediate  and  ultimate  results  of 
treatment.  If  this  were  not  so,  the  great  extension  in  the  use  of  this  remedy 
seen  both  in  Germany  and  England  would  be  unaccountable  :  for  example,  in  1905 
tuberculin  was  employed  in  36  out  of  123  private  and  public  sanatoria  in  Germany ; 
in  1906,  in  57  out  of  132  ;  and  in  1907,  in  77  out  of  135.  In  three  years,  then, 
the  figures  rose  from  29  to  57  per  cent.     To  my  mind,  the  best  summing  up  on 


PULMONARY     TUBERCULOSIS  429 

this  subject  is  that  of  Dr.  Lawrason  Brown,  who  says,  "  Tuberculin  when 
properly  given  does  no  harm,  may  produce  no  apparent  result,  and  ^may 
markedly  benefit  an  individual  patient  who  can  follow  at  the  same  time  the 
hygienic-dietetic  treatment  while  in  a  health  resort,  at  home,  at  rest,  or  at  work. 
Some  patients,  even  in  advanced  stages,  reap  great  benefit.  The  immediate  and 
ultimate  results  are  improved,  fewer  relapses  occur,  and  more  patients  lose  the 
tubercle  bacilli  in  their  sputum."  ^My  own  experience  is  to  the  effect  that 
patients  suffering  from  consumption,  and  in  whom  there  are  no  contra- 
indications against  the  use  of  tuberculin,  not  orily  lose  their  bacilli  in  greater 
numbers  when  tuberculin  is  effectively  administered  than  patients  who  do  not 
have  this  remedy,  but  suffer  from  relapses  less  frequently. 

Statistics  on  such  a  subject  tend  to  be  fallacious,  but  a  few  may  be  given  to 
support  the  above  generalizations.  The  problem  may  be  discussed  from, 
amongst  others,  three  points  of  view  :  (i)  The  disappearance  of  tubercle  bacilli 
from  the  expectoration  ;  (2)  The  immediate  results  of  treatment  from  a  clinical 
standpoint ;    (3)  The  ultimate  results. 

1.  The  Disappearance  of  Tubercle  Bacilli. — Dr.  Radcliff,  of  the  King  Edward  VII 
Sanatorium,  found  that  in  patients  treated  by  sanatorium  methods  and  no  tuber- 
culin, the  percentage  of  cases  in  which  the  bacilli  disappeared  was  as  follows  : — - 

Stage  I,  45-6  per  cent  ;  Stage  II,  19  per  cent ;  Stage  III,  8-9  per  cent  ;  or 
taking  all  cases  together,  2 3' 3  per  cent.  Loewenstein,  on  the  other  hand,  using 
a  more  searching  technique,  found  that  in  patients  treated  by  sanatorium  methods 
and  tubercuhn,  the  percentage  of  cases  in  which  the  bacilli  disappeared  was  as 
high  as  5"29  per  cent.  Bandeher,  in  a  similar  series,  found  the  percentage  to  be  : 
Stage  I,  100  per  cent  ;  Stage  II,  87'3  per  cent ;  Stage  III,  44^2  per  cent  ;  and 
Curschmann  gives  Stage  I,  80  per  cent  ;  Stage  II,  477  per  cent  ;  Stage  III,  33-7 
per  cent. 

We  may  say,  then,  that  so  far  as  statistics  go,  there  is  evidence  of  the  value 
of  tubercuhn  in  causing  the  disappearance  of  tubercle  bacilli  in  all  stages  ;  and 
that  when  we  take  all  cases  in  one  group,  we  find  that  with  sanatorium  methods 
alone  less  than  25  per  cent  of  the  patients  lose  the  bacilli  from  their  expectoration, 
but  that  when  tuberculin  is  added  to  the  treatment,  the  percentage  is  over  50. 

2.  The  Immediate  Results  of  Treatment  from  a  Clinical  Standpoint. — Trudeau 
found  that  in  the  incipient  cases  the  results  were  very  satisfactory  with  sana- 
torium methods  alone,  and  that  they  were  but  slightly  enhanced  by  the  use  of 
tuberculin.  In  the  moderately  advanced  cases  27  per  cent  of  those  in  whose 
treatment  tuberculin  was  given  were  cured,  as  against  6  per  cent  where  tuberculin 
was  not  given  ;  55  per  cent  were  arrested  when  tuberculin  was  given,  as  against 
51  per  cent  when  it  was  not  ;  whilst  iS  per  cent  remained  active  when 
tuberculin  was  given,  as  against  43  per  cent  when  it  was  not. 

3.  The  Ultimate  Results.- — Turban  found  that  of  86  patients  whose  sputum 
contained  bacilli  and  who  were  treated  with  tuberculin,  52 -3  per  cent  are  capable 
of  work  from  one  to  seven  years  after  their  discharge  from  the  sanatorium  ; 
whereas,  of  241  patients  whose  sputum  also  contained  bacilli  and  to  whom  no 
tuberculin  was  given,  only  39-4  per  cent  gave  a  similar  result.  Ritter  found  that 
the  following  percentage  of  his  patients  were  capable  of  work  one  to  four  j'ears 
after  their  discharge  from  his  sanatorium  (50  being  examined  only  about  one 
year  after  their  discharge) : — 

Patients  Capable  of  Work  One  to  Four  Years  after  Discharge 
FROM  Sanatorium  (Ritter). 

Stage  I. — Treated  with  tuberculin,  9.)  per  cent;  without  tuberculin,  72  per  cpnt 
„     n.--        ,,  „  „  82        „       ;         ,,  „  57 

„    in.—        „  ,,  „  50         „        ;  „  „  22 


430  INDEX     OF     PROGNOSIS 

Lawrason  Brown's  statistics  show  an  advantage  in  favour  of  tuberculin,  but 
to  a  slighter  extent.  Of  his  moderately  advanced  cases  discharged  with 
active  disease,  however,  41  per  cent  were  alive  of  those  treated  with  tuberculin 
one  to  fifteen  years  afterwards,  as  against  22  per  cent  of  those  not  so  treated. 

Arthur  Latham. 

PULSE,  IRREGULARITIES  OF  THE,— The  fundamental  principle  under- 
lying accuracy  of  prognosis  in  cardiac  arrhj^thmia  is  the  same  as  that  which  has 
been  enunciated  in  regard  to  cardiac  pain  ;  the  outlook  in  each  case  depends 
chiefly  on  the  cause,  for  arrhythmia,  like  angina,  is  only  a  symptom,  and  not 
in  itself  a  disease.  There  is,  however,  a  difference  between  the  two,  for  the 
type  of  irregularity  that  is  encountered  gives  valuable  intelligence  of  itself  as  to 
the  state  of  the  myocardium  ;  and  in  any  case  of  heart  disease  it  is  the 
myocardium,  and  especially  that  of  the  ventricles,  that  counts.  Each  kind  of 
irregularity  must  therefore  be  considered  on  its  own  merits,  as  well  as  in  connec- 
tion with  the  associated  lesions. 

Sinus  Irregularity. — This  comes  first  in  order  of  frequency,  as  well  as  of 
unimportance.  This  aberration,  in  which  the  whole  heart,  ventricle  as  well  as 
auricle,  participates,  is  always  due  to  extracardiac  causes,  and  is  therefore  never 
indicative  of  a  cardiac  lesion.  Practically,  therefore,  it  has  no  prognostic 
significance  ;  though  perhaps,  when  it  develops  in  a  case  of  meningitis  or  intra- 
cranial tumour,  it  may  be  regarded  as  evidence  of  increasing  pressure  within  the 
skull,  and  assessed  accordingly.  From  the  cardiac  point  of  view  it  is  of  the 
highest  importance  that  we  should  recognize  the  lack  of  significance  of  this  type 
of  arrhythmia  ;  for  it  is  extremely  common  in  childhood  and  youth  :  so  common 
indeed,  that  a  child  under  ten  with  a  perfectly  regular  pulse  is  a  clinical  curiosity. 
Nervous  subjects  are  in  like  manner  very  prone  to  exhibit  this  alteration  of 
rhythm.  When  the  pulse,  under  the  stress  of  supracardiac  influences,  shows 
an  extreme  degree  of  sinus  irregularity,  it  is  apt  to  alarm  both  patient  and 
medical  attendant,  unless  the  latter  has  assured  himself  of  its  harmless  origin. 
The  mere  fact  that  a  pulse  is  very  irregular  has  no  prognostic  meaning  ;  yet  there 
are  many  people  crawling  miserably  through  an  invalid  existence  to-day  because, 
being  possessed  of  an  exaggerated  sinus  irregularity  in  early  life,  they  were 
labelled  as  having  weak  hearts,  and  were  restricted  as  to  exercise.  Any  medical 
of&cer  to  a  public  school  can  tell  a  tale  of  boys  sent  to  school  with  certificates 
of  unfitness  for  games,  certificates  which  have  no  other  basis  than  a  sinus 
arrhythmia.  A  certificate  of  this  type  is  tantamount  to  malpraxis  ;  for  in  these 
days  of  graphic  methods  of  analyzing  the  heart's  rhythm,  there  is  no  excuse  at  all 
for  such  a  mistake.  Even  when  these  methods  are  not  available,  much  needless 
misery  might  be  avoided  if  it  could  be  realized  that  irregularity  of  the  pulse, 
no  matter  how  extreme,  is  of  no  significance  in  a  child  or  adolescent  who  shows 
no  other  evidence  of  cardiac  disease. 

The  Extrasystolic  Type  of  Arrhythma. — Of  this  condition  almost  the  same 
may  be  said.  Premature  contractions,  whether  arising  in  auricle,  ventricle,  or 
junctional  tissues,  are  due  in  some  cases  to  the  development  of  hypersensitive 
foci  in  the  myocardium,  in  others  to  extracardiac  influences  ;  not  even  in  the 
first  kind  of  case,  however,  does  the  extrasystole  count  for  much.  As  James 
Mackenzie  puts  it,  even  in  elderly  people  the  extrasystole  is  of  no  more  importance 
than  the  presence  of  tortuous  temporal  arteries.  The  writer  has  often  seen 
extrasystoles  develop  in  persons  at  or  past  nfiddle  life,  without  other  signs  of 
cardiac  disease,  and  continue  intermittently  or  persistently  for  years,  without 
introducing  any  hurtful  condition  other  than  the  mild  panic  which  is  often 
experienced  by  patients  who  have  become  aware  of  their  own  extrasystoles. 
Even  in  cases  where  the  pulse  is  confused  by  a  whole  medley  of  these  premature 


PULSE,     IRREGULARITIES     OF     THE  431 

ectopic  beats,  the  outlook  is  no  worse  than  in  cases  where  the  extrasystole  is 
occasional. 

When  this  type  of  irregular  pulse  makes  its  appearance  for  the  first  time  in  a 
case  of  organic  heart  disease,  it  is  rarely  of  any  significance.  There  are  two 
exceptions  to  this  rule.  The  first  of  these  is  the  case  of  the  patient  with  advanced 
post-rheumatic  disease  of  the  mitral  valve — cases  which  usually  fall  within  the 
category  of  mitral  stenosis.  Here  the  appearance  of  auricular  extrasystoles 
may  sometimes  foreshadow  the  descent  of  the  heart  into  that  condition  of  total 
irregularity  which  may  be  regarded  as  the  beginning  of  the  end  [vide  infra, 
'Total  Arrhythmia').  But  this  sequence  is  by  no  means  inevitable,  and  it 
w^ould  be  very  bad  practice  to  frighten  the  patient  by  any  mention  of  its 
possibility.  The  other  exception  is  sometimes  encountered  in  persons  whose 
ventricular  contractility  is  becoming  impaired  by  cardiosclerosis  or  other 
progressive  myocardial  disease.  An  extremely  significant  proof  of  this  impair- 
ment is  furnished  by  the  supervention  of  the  alternating  pulse  {vide  infra). 
In  a  few  cases  this  alternating  pulse  is  first,  and  for  short  periods,  set  in  motion 
by  an  extrasystole  ;  first  comes  an  extrasystole,  and  then  follows  a  bout  of 
alternating  beats.  Even  here,  however,  it  is  not  so  much  the  extrasystole  as 
that  which  it  '  unmasks  '  (to  borrow  Lewis's  word)  that  is  of  grave  import. 

As  a  general  rule,  therefore,  it  is  true  to  say  that  the  extrasystole  may  be 
ignored  so  far  as  the  prognosis  is  concerned.  There  is  no  form  of  irregularity 
of  which  the  patient  himself  is  more  painfully  aware  than  this  ;  and  his  restoration 
to  a  sense  of  well-being  is  often  largely  dependent  on  the  confidence  with  which 
his  medical  adviser  is  able  to  say  that  there  is  nothing  the  matter  with  him.  The 
assurance  that  must  necessarily  underlie  the  delivery  of  such  a  statement  is 
scarcely  possible  of  attainment,  in  many  cases,  except  by  means  of  graphic 
analysis  of  the  pulse  irregularity,  or  apart  from  that  familiarity  with  the  meaning 
of  the  various  kinds  of  arrhythmia  which  it  is  hard  to  acquire  without  the  practice 
of  graphic  methods.  There  is  no  area  in  the  whole  range  of  medicine  where 
accurate  prognosis  is  more  absolutely  dependent  on  accurate  diagnosis  than  that 
of  cardiac  arrhythmia. 

Tachycardia. — This  is  the  next  kind  of  irregularity  to  be  considered.  Here 
it  is  first  necessary  to  discriminate  between  quickening  of  the  pulse  by  cardiac 
causes  and  that  due  to  extracardiac  influences.  Tachycardias  of  the  former 
class,  such  as  those  of  hyperthyroidism  and  the  fevers,  are  of  course  outside  the 
purpose  of  this  paragraph.  Persistent  rapidity  of  the  pulse,  other  things  being 
equal,  is  not  a  good  sign  in  heart  disease,  but  it  scarcely  comes  under  the 
heading  of  '  irregularity.'  This  practically  limits  the  subject  to  a  consideration 
of  paroxysmal  tachycardia,  of  a  disorder,  that  is  to  say,  that  is  characterized 
by  attacks  of  rapid,  regular  pulse.  Such  attacks  begin  and  end  abruptty, 
without  any  gradual  transition  from  or  into  the  normal  rate. 

Here  the  prognosis  turns  not  so  much  on  the  nature  of  the  attack  itself  as  on 
the  condition  of  the  heart  between  and  during  the  paroxysms.  The  best  kind 
of  case  is  that  which  occurs  in  an  otherwise  healthy  5'oung  adult  with  no  evi- 
dences of  organic  disease  of  the  heart.  The  worst  kind  is  that  in  which  the 
patient  is  afflicted  with  advanced  heart  disease  of  the  post-rheumatic  or  of  the 
cardiosclerotic  type,  and  in  which  each  bout  of  tachycardia  aggravates  the 
signs  of  cardiac  insufficiency  (oedema,  dyspnoea,  alternating  pulse,  and  the  hke). 
The  import  of  paroxysm.al  tachycardia  is  graver,  the  older  the  patient  ;  in 
persons  at  or  past  middle  life  these  attacks  are  apt  to  reveal  myocardial 
inadequacy,  even  where  it  was  not  otherwise  suspected,  in  the  following  manner  : 
when  the  heart  has  been  beating  at  its  heightened  speed  for  a  little  time,  the 
excessive  call  for  ventricular  work  begins  to  induce  fatigue  of  the  myocardium. 


432 


INDEX     OF    PROGNOSIS 


which  is  evidenced  by  shortness  of  breath,  precordial  distress,  cyanosis,  alter- 
nating pulse,  and  even  dropsy.  Such  phenomena  are  specially  liable  to  occur  in 
elderly  persons,  and  they  have  a  doubly  ominous  significance :  in  the  first  place, 
they  discover  mj^ocardial  shortcomings  that  were  not  previously  known  to  exist ; 
and,  further,  each  attack  throws  a  fresh  overstrain  on  a  ventricular  wall  which 
is  already  taxed  to  its  utmost  by  the  ordinary  calls  of  life,  and  thus  aggravates 
its  inadequacy.  Other  things  being  equal,  a  fast  tachycardia  is  more  exhausting 
to  the  ventricular  contractility  than  a  relatively  slow  one  ;  Wenckebach 
considers  that  there  is  a  '  critical  speed  '  of  i8o  per  minute,  at  which  the 
ventricular  systole  of  one  cardiac  cycle  coincides  with  the  auricular  systole  of 
the  next  cycle,  producing  what  he  calls  '  obstipatio  sanguinis.'  It  should  be 
added  that  patients  do  not  die  during  attacks,  though  the  foregoing  remarks 
will  suffice  to  impress  the  gravity  of  the  overstrain  thrown  by  a  prolonged  bout 
of  tachycardia  on  a  heart  that  is  already  seriously  diseased. 

To  sum  up  what  has  been  said  as  to  the  general  outlook  in  paroxysmal  tachy- 
cardia :  it  is  of  grave  import  in  proportion  to  the  amount  of  ventricular  weakness 
which  it  reveals  or  induces.  This  answers  the  first  question  put  by  patients 
suffering  from  this  trouble,  as  to  its  significance  in  regard  to  life  prospects. 

But  they  are  also,  and  not  unnaturally,  concerned  to  know  how  far  they  are 
to  expect  relief  from  the  acute  discomfort  of  mind  and  body  occasioned  by  each 
attack.  To  this  question  it  is  extremely  difficult  to  give  a  satisfactory  reply. 
Each  case  appears  to  have  its  own  remedies,  and  it  is  impossible  to  prophesy 
success  from  the  use  of  any  single  one  of  them.  On  the  other  hand,  no  case 
ought  to  be  regarded  as  incurable  :  even  where  it  is  an  accompaniment  of  grave 
organic  lesions,  this  type  of  irregularity  may  disappear  completely.  Neither  is 
prolonged  duration  to  be  accepted  as  evidence  of  incurability  ;  cases  of  years' 
duration  have  been  known  to  clear  up  entirely. 

Other  types  of  tachycardial  paroxysm — those  which  constitute  varieties  of 
auricular  flutter  and  fibrillation  respectively — will  be  considered  under  those 
headings. 

Auricular  Flutter. — The  next  form  of  arrhythmia  which  calls  for  notice  is  this 
newly-defined  condition.  This  is  a  tachycardia,  usually  paroxysmal,  or  at  least 
periodic,  arising  in  the  auricle,  which  beats  regularly  but  at  a  great  rate.  Some- 
times all  these  fast  beats  come  through  to  the  ventricle,  but  more  often  they — 
or  rather  a  proportion  of  them — are  blocked  in  transit,  so  that  the  ventricular 
rate  is  one-half,  one-third,  or  one-quarter  of  the  auricular.  The  writer  recently 
had  occasion  to  review  the  published  reports  of  this  condition,  and  summarized 
the  prognosis  by  saying  that  "  auricular  flutter  has  no  grave  significance  so  far 
as  is  known,  except  where  it  occurs  in  cases  of  organic  heart  disease.  Here  it 
betrays  a  fairly  advanced  degeneration  of  the  auricular  musculature,  and  it  adds 
to  the  burden  of  the  heart  by  excessive  speeding  up  of  the  ventricle."  To  this 
may  be  added  the  fact  that  flutter  seems  to  pass  over  into  fibrillation  of  the 
auricle  in  some  cases — a  possibility  which  is  of  course  evidence  of  the  fact  that 
flutter  is  a  sign  of  auricular  degeneration  when  it  is  associated  with  organic 
disease  of  the  heart. 

Totally  Irregular  Pulse — Auricular  Fibrillation. — We  come  next  to  the 
consideration  of  the  totally  irregular  pulse — the  most  consistently  organic  of 
the  recognized  types  of  arrhythmia.  It  is  now  recognized  universally  that  this 
disturbance  of  the  heart's  action  arises  in  a  phenomenon  known  as  auricular 
fibrillation  (Lewis),  consisting  of  replacement  of  the  orderly  auricular  systole 
by  a  disordered  tremulous  movement  of  the  whole  auricular  musculature.  This 
latter  appears  to  originate  from  many  irritable  foci  in  the  auricular  myocardium 
taking  over  the  function  of    stimulus  production,   and    the    result  is   that  an 


PULSE,     IRREGULARITIES     OF     THE  433 

absolutely  irregular  stream  of  stimuli  is  rained  down  by  the  fibrillating  auricle 
into  the  ventricle.  Clinically  this  makes  itself  apparent  in  an  irregular  pulse — 
not  merely  an  occasional  disturbance  of  an  otherwise  normal  rhythm,  but  a  total 
absence  of  rhythm  of  any  kind.  Added  to  this,  the  usual  evidences  of  auricular 
contraction  disappear  from  the  graphic  records  and  from  the  other  physical 
signs. 

When  this  rhythm  first  makes  its  appearance  in  a  case  of  heart  disease 
(nearly  always  either  post-rheumatic  or  cardiosclerotic)  it  means  that  the  wall 
of  the  auricle  has  reached  a  certain  stage  in  its  downward  career.  The  forces 
that  are  tampering  with  its  food-supply  have  carried  their  nefarious  designs  to 
a  definite  point  of  success.  The  first  prognostic  fact  in  relation  to  the  totally 
irregular  pulse  is  therefore  this,  that  it  is  an  unmistakable  mark  of  auricular 
degeneration.  Even  where  this  disorder  first  makes  its  appearance  in  transitory 
attacks,  between  which  the  rhythm  returns  to  the  normal,  it  is  sure  to  become 
permanent  sooner  or  later.  Ninety-nine  times  out  of  a  hundred,  then  (for  it 
seems  that  there  are  rare  exceptions),  total  arrhythmia  spells  grave  organic 
disease. 

The  next  question  to  be  answered  is  the  expectation  of  life  after  this  dis- 
turbance has  appeared.  As  to  this,  there  is  a  difficulty  which  may  be  best 
illustrated  by  contrasting  two  cases  recently  under  the  writer's  observation. 
At  one  end  of  the  scale  was  the  case  of  an  elderly  man  with  cardio- 
sclerotic and  alcoholic  degeneration  of  the  myocardium,  who  died  only  twelve 
days  after  the  pulse  had  become  totally  irregular.  At  the  other  end  comes  a 
man  with  mitral  stenosis  whose  pulse  was  found  to  be  quite  irregular  over 
four  years  ago ;  yet  this  has  not  prevented  him  from  keeping  on  at  his 
rather  laborious  work  in  a  tan-yard,  practically  without  intermission,  since 
that  time.  The  explanation  of  this  discrepancy  is  to  be  found  in  the  fact 
that  the  ventricle,  and  not  the  auricle,  is  the  vital  part  of  the  heart. 
The  danger  of  the  totally  irregular  pulse  is  probably  twofold  :  in  the  first 
place,  the  rapid,  irregular  stream  of  stimuh  pouring  down  on  the  ventricle 
from  the  auricle  imposes  a  great  strain  on  the  former  ;  and  secondly,  if  the 
auricle  is  out  of  action,  this  adds  somewhat  to  that  venous  stasis  which  does  so 
profound  an  injury  to  the  nutrition  of  the  myocardium  (among  other  tissues), 
and  thus  assists  materially  in  precipitating  cardiac  downfall.  It  is  the  first 
of  these  factors  that  is  the  more  immediately  dangerous  ;  and  in  any  case  it  is 
the  condition  of  the  ventricular  wall  on  which  depends  the  ultimate  fate  of  the 
heart,  as  to  whether  it  shall  continue  to  work  effectively  or  not.  The  two  cases 
mentioned  above  bring  out  this  point  very  strongly  ;  in  the  first,  alcohol  and 
senility  had  already  reduced  the  ventricular  myocardium  to  the  verge  of  bank- 
ruptcy, so  that  the  onset  of  an  irregular  pulse  proved  to  be  the  last  straw.  In 
the  other,  the  active  phase  of  the  rheumatic  infection  was  long  past,  and,  as  is 
often  the  case  under  such  circumstances,  the  ventricle  was  almost  well  again, 
so  that  it  was  able  to  carry  on  the  circulation,  though  exposed  to  the  additional 
worry  of  a  rapid  and  disorderly  series  of  stimuli  descending  on  it  from  above. 

It  is  the  paramount  importance  of  the  ventricle  that  explains  the  contrast 
between  the  behaviour  of  the  cardiosclerotic  and  the  post-rheumatic  heart 
respectively,  after  the  supervention  of  total  arrhythmia.  In  the  first  of 
these,  the  arterial  degeneration  that  has  undermined  the  efficiency  of  the 
auricular  wall  has  been  equally  active  in  its  attack  on  the  ventricular  myo- 
cardium ;  so  that  when  the  stage  is  reached  at  which  the  auricular  rhythm 
goes  wrong  and  thus  imposes  an  extra  strain  on  the  ventricle,  that  structure 
is  already  barely  able  to  cope  with  the  demands  made  upon  it  by  the  ordinary 
rate  and  rhythm  of  stimulation.     In  the  post-rheumatic  type  of  heart  disease, 

28 


434  INDEX    OF    PROGNOSIS 

on  the  other  hand,  the  degenerative  changes  induced  in  the  cardiac  wall  by 
overwork  and  chronic  stasis  proceed  more  quickly  in  the  auricles  than  in  the 
ventricles,  because  in  every  such  case  there  is  mitral  obstruction,  which  throws 
the  burden  of  overstress  upon  the  auricular  wall.  As  a  result,  the  auricle  breaks 
down  and  fibrillates,  while  the  ventricle  still  has  plenty  of  work  left  in  it. 
Consequently  the  new  burden  thrown  upon  it  by  the  disorderly  behaviour 
of  the  auricle  fails  to  overwhelm  it.  The  dominant  importance  of  ventricular 
integrity  explains  the  different  way  in  which  some  cases  of  mitral  stenosis 
respond  to  the  onset  of  auricular  fibrillation  and  the  total  arrhythmia 
dependent  thereon.  In  some,  the  rheumatic  process  that  estabhshed  the 
valvular  deformity,  at  the  same  time  injured  the  ventricular  myocardium  and 
induced  dilatation  ;  for  various  reasons  this  is  more  persistent  in  some  cases 
than  in  others,  and  it  is  in  such  that  the  supervention  of  the  totally  irregular 
rhythm  produces  its  most  deiinite  effects  so  far  as  this  type  of  cardiac  disease 
is  concerned. 

So  far,  then,  our  conclusion  is  that  in  any  given  case  exhibiting  the  total 
arrhythmia  of  auricular  fibrillation,  the  outlook  turns  on  the  condition  of  the 
ventricle.  It  remains  to  translate  this  into  chnical  terminology.  First,  the 
prognosis  is  generally  better  if  the  underlying  disease  be  post-rheumatic  than 
if  it  be  cardiosclerotic,  alcoholic,  or  syphiUtic  in  origin.  Second,  bad  signs  are 
oedema,  anginal  pain,  and  grouped  respirations.  The  more  pronounced  and 
easily  provoked  the  dyspnoea,  the  worse  the  prognosis.  And  finally,  the  extent 
to  which  the  symptoms  improve  under  the  influence  of  rest  and  digitalis,  measures 
which  meet  with  quite  a  remarkable  response  in  some  cases  and  none  at  all  in 
others,  is  an  important  index  of  probabilities.  The  pulse  should  become  slower, 
the  output  of  urine  should  increase,  and  the  subjective  symptoms  should  be 
definitely  mitigated,  within  a  few  days — a  week  at  the  outside — of  the  institution 
of  such  treatment.  If  this  improvement  is  not  manifest,  it  means  that  the  patient 
is  incapable  of  receiving  benefit  from  any  form  of  help  ;  and  the  gravity  of  the 
prognosis  is  directly  proportional  to  this  insensibility  to  appropriate  therapeutics. 

To  sum  up  :  the  appearance  of  total  arrhythmia  in  any  case  of  heart  disease 
adds  to  the  gravity  of  the  prognosis.  In  any  given  case  the  future  depends  upon 
the  efficiency  or  otherwise  of  the  ventricle,  and  on  the  response  to  treatment. 

Heart-block. — Here  the  prognosis  is  necessarily  grave.  This  is  not  to  say  that 
it  is  an  irrecoverable  phase  of  heart  disease.  In  many  cases  of  extreme  heart- 
block  the  unexpected  has  happened  ;  the  normal  rhythm  has  been  restored : 
but  the  general  rule  is  that  heart-block  depends  on  gross  organic  disease  involving 
central  and  vital  portions  of  the  myocardium. 

The  risk  of  sudden  asystole  is  considerable  where  there  are  the  syncopal  or 
epileptiform  attacks  which,  when  they  coincide  with  the  long  pulse  pauses  of 
heart-block,  constitute  the  Stokes-Adams  syndrome.  Patients  who  suffer  in 
this  way  may  go  out  quite  abruptly,  being  found  dead  in  bed  or  the  hke  ;  or  they 
may  be  quickly  exhausted  by  a  rapid  series  of  such  attacks  occurring  at  brief 
intervals.  In  milder  cases,  where  only  every  fourth,  third,  or  even  second  beat 
drops  out,  the  prospect  of  sudden  death  from  block  and  syncope  is  remote, 
provided  the  patient  is  willing  and  able  to  restrict  his  activities  within  the  hmits 
allowed  him  by  his  cardiac  lesion. 

In  any  individual  case  of  heart-block,  there  are  four  considerations  upon 
which  the  prognosis  rests.  The  nature  of  the  lesion  causing  the  block  is  the  first 
of  these.  Acute  heart-block — i.e.,  injury  to  conductivity  by  an  infective  lesion 
of  the  myocardium — is  usually  slight  and  transitory  ;  it  does  not  appear  greatly 
to  pervert  the  course  of  the  disease  from  that  which  it  would  have  followed  if  no 
heart-block   had    occurred.     In    ulcerative    endocarditis,    however,    the    super- 


PULSE,     IRREGULARITIES     OF     THE  435 

vention  of  heart-block  may  be  a  serious  feature  ;  it  may  indicate  direct  extension 
of  a  burro\ving  ulceration  into  the  auriculo-ventricular  connections.  Chronic 
heart-block  is  much  more  often  encountered  than  that  due  to  acute  lesions. 
Its  commonest  causes  are  arteriosclerosis  and  syphilis.  Of  these  two,  the  latter 
gives  the  best  chance  of  recovery,  since  it  is  amenable  to  specific  treatment. 
Even  so,  however,  cure  is  only  effected  in  a  few  cases.  The  arteriosclerotic 
cases  tend  to  get  worse,  slowly  as  a  rule,  sometimes  rapidly. 

This  introduces  the  two  other  points  of  importance — the  degree  of  block 
present,  and  the  course  which  it  follows  under  observation.  It  is  pretty  obvious 
that  the  advanced  degrees  of  block  are  more  to  be  feared  than  comparatively 
mild  phases  ;  but  in  estimating  the  bearing  which  the  point  has  on  the  prognosis, 
it  is  essential  to  take  into  consideration  the  progress  or  otherwise  of  the  inter- 
ruption of  conductivity.  This  is  best  illustrated  by  comparing  two  cases  recently 
under  the  writer's  care.  The  first  patient  was  an  old  lady  with  pronounced 
arterial  degeneration.  Her  illness  began  with  occasional  attacks  of  block  ;  but 
within  a  week  it  was  practically  continuous,  and  in  ten  days  from  the  onset  she 
was  dead.  The  other  patient,  an  elderly  man  of  placid  temperament,  gives  a 
history  of  ten  years'  bradycardia  and  fainting  attacks.  He  hves  quietly,  and 
though  he  has,  for  several  years  at  least,  been  the  subject  of  complete  heart-block, 
he  seems  little  the  worse  for  it  so  long  as  he  refrains  from  physical  or  mental 
stress.  His  cardiac  symptoms  have  made  no  perceptible  progress  for  years. 
This  comparison  affords  a  vivid  illustration  of  the  fact  that  a  severe  but 
stationary  degree  of  block  is  less  minatory  than  a  mild  but  progressive  case. 

One  more  point  will  arise  for  consideration  in  any  given  case — the  other  signs 
of  cardiac  disease.  So  far  as  the  likelihood  of  a  fatal  issue  is  concerned,  a  bad 
prognosis  is  of  course  inevitable  when  there  are  signs  of  impaired  contractility 
in  addition  to  the  evidences  of  interrupted  conduction  ;  in  such  a  case  it  is 
obvious  that  the  block  may  be  of  minor  importance,  the  outlook  depending  more 
directly  on  the  state  of  the  other  myocardial  functions.  If,  however,  we  are 
essaying  a  forecast  of  the  course  that  the  block  itself  wiU  follow,  then  the  general 
condition  of  the  heart  makes  rather  less  difference,  except  that  gross  enfeeble- 
ment  of  contractile  power  tends  to  accelerate  the  destruction  of  the  conducting 
function.  As  for  the  possibiUty  of  lessening  block  by  treatment,  apart  from 
the  syphilitic  type  of  case  spoken  of  above,  nothing  has  any  direct  effect  as 
a  rule. 

Alternating  Pulse. — One  other  aberration  of  the  pulse  is  generally  included  in 
descriptions  of  arrhythmia,  the  alternating  pulse.  This  term  should  include 
nothing  except  the  alternation  of  weak  and  strong  beats  of  the  same  length. 
When  this  is  encountered,  it  is  always  a  sign  of  advanced  or  advancing  exhaustion 
of  contractility — par  excellence  the  vital  function  of  the  myocardium.  It  is 
therefore  an  ominous  feature  of  any  case  of  heart  disease.  It  is  true  that  in  some 
cases  its  first  appearances  are  transitory  ;  it  may  be  detected  during  a  bout 
of  paroxysmal  tachycardia,  or  for  a  few  beats  following  an  extrasystole  ;  even 
so,  it  is  to  be  received  as  a  forewarning  of  further  troubles  to  come,  and  even 
where  it  is  unsupported  by  other  evidence  of  myocardial  deterioration,  it  forms 
sufficient  reason,  of  itself,  for  warning  the  patient  that  his  activities  must  be 
restricted  in  future. 

Summary. — The  aim  of  this  article  has  been  to  show  that  in  any  case  marked 
by  irregularity  of  the  pulse,  this  symptom  should  always  be  analyzed  so  that  its 
exact  mode  of  origin  may  be  determined  ;  and  further,  that  it  should  always  be 
considered  in  conjunction  with  the  other  means  of  examining  the  heart.  Nothing 
is  more  wildly  inaccurate  than  prognosis  founded  on  the  degree  of  arrhythmia 
withont  scientific  exploration  of  its  origin.  Carey  F.  Coombs. 


436  INDEX    OF    PROGNOSIS 

PURPURA. — Purpura  is  to  be  regarded  as  a  symptom  rather  than  a  disease. 
It  appears  to  depend  upon  a  defect  in  the  small  vessels,  probably  the  veins. 
In  many  instances  it  is  a  mere  incident  in  the  course  of  a  disease,  and  such 
cases  need  not  be  discussed  here. 

The  following  special  varieties  are  recognized  :  (i)  Purpura  simplex ; 
(2)  Purpura  hcemorrhagica ;  (3)  Schonlein's  purpura  (Peliosis  rheumatica)  ; 
(4)   Henoch's  purpura. 

Statistics  regarding  cases  of  purpura  give  little  help  in  regard  to  prognosis, 
since  the  severity  of  the  different  types  varies  greatly.  It  may  be  noted, 
however,  that  Mackenzie  found  the  mortality  in  a  series  of  200  consecutive 
cases  to  be  14  per  cent. 

As  a  general  statement,  it  may  be  said  that  the  severity  of  purpura  increases 
with  advancing  j'ears.  In  purpuric  subjects,  attacks  are  liable  to  become 
more  frequent  and  the  resulting  anaemia  is  more  severe. 

1.  Purpura  Simplex. — -This  is  a  mild  form  usually  seen  in  children.  The 
haemorrhages  are  seldom  larger  than  petechiae,  and  in  most  cases  are  confined 
to  the  limbs.  Prognosis  is  favourable.  Successive  crops  of  spots  may  appear 
for  three  or  four  days,  but  as  a  rule  the  patient  is  well  within  a  fortnight,  although 
the  pigmented  spots  may  be  seen  for  some  weeks.  The  associated  symptoms, 
such  as  fever  or  diarrhoea,  never  give  rise  to  serious  trouble. 

In  a  few  instances  an  attack  of  purpura  simplex  has  been  followed  by  symptonis 
of  purpura  hasmorrhagica. 

Cases  have  been  reported  in  w-hich  the  purpuric  spots  were  followed  by  gangrene. 
Some  of  these  are  to  be  explained  by  the  administration  of  salicylates  or  iodides. 
Apart  from  such  causes  they  are  extremely  rare. 

2.  Purpura  Hsemorrhagica. — This  is  the  most  formidable  type  of  purpura. 
Prognosis  may  be  the  more  serious  from  the  fact  that  it  usually  affects  children 
already  in  delicate  health,  although  it  also  attacks  adults.  The  purpuric  spots 
appear  and  soon  increase  in  number  and  in  size. 

Epistaxis,  bleeding  from  the  gums,  haematemesis,  haematuria,  and,  less 
comm^only,  haemoptysis  may  occur.  The  patient  becomes  profoundly  anaemic 
with  great  rapidity.  In  a  week  the  corpuscles  may  have  fallen  to  50  per  cent. 
Cases  of  purpura  fulminans,  occurring  especially  in  children,  may  be  fatal  within 
twenty-four  hours  ;  in  some  of  these  the  end  comes  before  there  has  been  any 
obvious  bleeding  from  the  mucous  membranes. 

Cerebral  haemorrhage,  kidney  disease,  haemorrhage  into  the  suprarenals,  and 
heart-failure  or  exhaustion  from  repeated  bleedings,  may  also  lead  to  a  fatal 
result. 

In  favourable  cases,  symptoms  cease  or  lessen  in  from  one  to  two  weeks.  There 
is  always  a  prolonged  period  of  convalescence.  Patients  are  weak  and  emaciated, 
and  several  months  may  elapse  before  the  blood  regains  its  normal  condition. 
While  we  must  regard  prognosis  in  purpura  hasmorrhagica  as  somewhat  grave, 
perha.ps  the  most  striking  thing  about  it  is  the  large  proportion  of  very  severe 
cases  which  recover. 

The  chief  points  on  which  we  can  base  a  prognosis  are  as  follows  :  The  more 
severe  and  frequent  the  cutaneous  haemorrhages,  the  more  serious  is  the  case. 
Haemorrhages  from  the  mucous  membranes,  if  at  all  severe,  add  to  the  gravity 
of  the  condition  ;  of  these,  epistaxis  has  probably  the  least  serious  significance. 
Haemorrhage  from  many  mucous  membranes  is  more  serious  than  from  one. 
Marked  pyrexia,  albuminuria,  constitutional  disturbance,  and  mental  depression 
are  unfavourable  signs.  Accurate  information  regarding  the  effect  and  progress 
of  the  hemorrhages  is  to  be  obtained  by  a  frequent  use  of  the  haemocytometer 
and  haemoglobinometer. 


PYELOCYSTITIS  437 

An  intermediate  group  of  cases  is  that  in  which  special  symptoms  associated 
with  the  haemorrhages  arise.  These  include  the  occurrence  of  blebs,  ulcers,  or 
necrosis  as  the  result  of  the  cutaneous  haemorrhages  ;  haemorrhages  into  the 
tongue  may  give  rise  to  great  swelling  and  tension,  and  may  even  call  for  relief 
by  incision ;  recurring  epistaxis  may  persist  after  other  symptoms  have  been 
arrested. 

3.  Schonlein's  Purpura  (Peliosis  Rheumatica). — This  variety  is  associated 
with  pain  and  swelling  in  the  joints,  urticarial  and  inflammatory  lesions  of  the 
skin,  and  a  variable  degree  of  fever.  The  outcome  is  usually  quite  favourable. 
Fatal  cases  have  occurred,  but  with  great  rarity.  It  is,  however,  associated  with 
a  very  large  number  of  possible  complications,  and  recurrence  of  the  disease  is 
exceedingly  common.  The  symptoms  of  an  attack  may  be  very  persistent  ; 
recurring  crops  of  petechiae  and  attacks  of  fever  and  arthritis  may  persist  for 
over  a  year. 

A  very  potent  factor  in  determining  relapses  is  exertion,  and  it  may  be  stated 
here  that  rest  in  bed  is  the  one  therapeutic  measure  of  outstanding  importance 
in  all  forms  of  purpura.  Pharyngitis,  sometimes  so  severe  as  to  lead  to  gangrene 
of  the  tonsils  and  uvula,  may  occur.  The  other  complications  are  those  usually 
associated  with  rheumatism ;  endocarditis,  pericarditis,  pleurisy,  albuminuria, 
chorea,  and  hyperpyrexia  may  supervene. 

It  should  be  remembered,  however,  that  in  spite  of  the  somewhat  formidable 
list  of  possible  contingencies,  their  actual  occurrence  is  so  rare  that  peliosis 
rheumatica  in  the  average  case  may  be  regarded  as  a  benign  affection. 

4.  Henoch's  Purpura. — This  variety  is  associated  with  vomiting,  colic,  and 
diarrhoea.  A  considerable  number  of  cases  associated  with  intussusception  are 
on  record.  There  are  joint  swellings,  and  cutaneous  affections  such  as  erythema 
may  accompany  the  purpura.  Actual  haemorrhages  from  mucous  membranes 
may  occur. 

Prognosis  is  fairly  good,  but  a  fatal  outcome  may  take  place.  Osier  recorded 
3  deaths  in  a  series  of  11  cases.  In  one  the  fatal  outcome  was  the  result  of 
an  intense  hemorrhagic  nephritis. 

Haemorrhage  from  mucous  membranes,  nephritis,  and  exhaustion  are  the  chief 
dangers,  in  the  absence  of  any  association  with  a  grave  abdominal  condition. 
When  intussusception  is  present,  it  dominates  the  position  as  regards  prognosis, 
but  it  is,  of  course,  more  dangerous  because  of  the  purpura. 

Relapses  are  a  common  feature,  and  attacks  of  Henoch's  purpura  may  recur 
for  years.  g.  L.  Gulland. 

A.  Goodall. 

PYELOCYSTITIS. — Pyelocystitis  includes  a  number  of  conditions  differing 
in  gravity,  and  therefore  varying  in  prognosis.  The  infection  is  most  commonly 
due  to  the  B.  coli  communis,   which  is  usually  present  in  pure  culture. 

B.  coli  pyelocystitis  is  acute  or  chronic  ;  and  it  may  be  uncomplicated  or 
complicated.  In  acute  uncomplicated  B.  coli  pyelocystitis  the  infection  has 
occurred  in  a  previously  healthy  urinary  tract.  The  origin  may  be  traced  to 
haemorrhoids,  acute  or  chronic  colitis,  appendicitis,  chronic  constipation, 
dysentery,  or  some  other  intestinal  trouble,  or  there  may  be  no  apparent  cause. 
The  attack  may  be  moderate  or  severe.  It  is  usually  possible  during  the  first 
two  days  to  form  an  estimate  of  its  probable  severity. 

In  a  moderate  attack,  the  temperature  may  rise  to  101°  or  102°,  and  is  ushered 
in  by  a  slight  shivering  or  a  feeling  of  chilliness.  The  bladder  symptoms  may 
be  severe  and  distressing.  Kidney  symptoms  are  less  prominent,  amounting 
to  slight  pain  and  tenderness,  but  no  enlargement  of  the  organ  ;  they  may  be 
entirely  absent. 


438  INDEX    OF    PROGNOSIS 

In  a  severe  attack  the  initial  rigor  is  also  severe,  and  may  be  repeated  ;  the 
temperature  rises  to  102°  or  104°,  or  even  to  105°  F.,  and  the  patient  shows 
evidence  of  profound  toxaemia.  There  is  severe  pain  in  the  kidney,  the  abdo- 
minal muscles  are  rigid,  the  kidney  region  is  tender,  and  the  kidney,  if  it  can 
be  felt,  is  enlarged. 

A  mild  attack  such  as  has  been  sketched  above  may  be  expected  to  last  for 
ten  or  fourteen  days.  There  is  no  danger  to  life,  and  the  principal  points  in 
the  prognosis  are  :  that  relapses  are  very  frequent  if  the  patient  is  allowed  to 
get  up  or  to  go  out  too  soon  ;  and  that  it  is  impossible  to  say,  even  in  a  mild 
attack  of  pyelocystitis,  whether  a  bacilluria  may  not  persist  and  give  rise  to 
future  trouble. 

In  a  severe  attack  there  is  danger  to  life.  If  the  patient  is  old,  or  very  stout, 
or  bronchitic,  or  otherwise  incapable  of  withstanding  a  severe  toxaemia,  he 
will  probably  succumb  after  a  week  or  ten  days.  On  the  other  hand,  when  the 
patient  suffers  from  no  such  complication,  the  immediate  prognosis  is  more 
favourable.  The  temperature  remains  high  for  about  a  week,  but  after  that 
time  should  commence  to  fall,  and  at  the  end  of  ten  or  fourteen  days  from  the 
onset  of  the  illness  will  have  reached  normal.  If  the  temperature  remains 
high  and  the  symptoms  show  no  sign  of  abating  at  the  end  of  a  week,  the  out- 
look is  less  favourable,  and  will,  if  no  improvement  occurs  in  the  next  three  or 
four  days,  become  grave.  After  one  or  more  of  such  relapses,  the  patient 
usually  succumbs.  Operation  in  such  cases  should  not  be  too  long  delayed. 
If  at  the  end  of  a  week  the  acute  symptoms  persist,  and  the  patient  is  beginning 
to  lose  ground,  operation  should  be  performed. 

The  results  of  nephrotomy  are  not  very  satisfactory.  In  20  cases  of 
nephrotomy  for  acute  pyelonephritis,  there  were  7  deaths  (35  per  cent).  In 
surviving  cases,  the  late  results  are  also  unsatisfactory  :  the  acute  symptoms 
subside,  but  chronic  pyelonephritis  persists,  and  nephrectomy  may  be  required 
at  a  later  date. 

The  best  results  in  acute  cases  have  been  obtained  by  nephrectomy,  after 
ascertaining  that  the  second  kidney  is  healthy.  In  17  cases  of  nephrectomy 
there  were  no  deaths. 

Where  the  acute  symptoms  subside  without  operation,  the  infection  in  some 
cases  disappears.  In  a  large  number  of  cases,  however,  it  persists  in  a  mild 
form,  the  principal  symptoms  being  those  of  slight  chronic  cystitis.  In  such 
cases  there  is  a  constant  danger  of  recurrence — which  takes  place  sometimes 
after  short  intervals,  and  sonietimes  after  some  years.  Secondary  stone- 
formation  in  the  renal  pelvis  or  in  the  bladder  is  not  uncommon  in  such  cases, 
and  there  is  a  danger  of  ascending  pyelonephritis  of  the  healthy  kidney,  leading 
to  suppression  of  urine  and  death.  Some  cases  go  on  for  many  years  without 
any  change,  but  the  patient  suffers  chronic  ill  health,  and  is  unfit  for  great  or 
prolonged  efforts,  either  physical  or  mental.  In  some  of  these  cases  the 
original  focus  of  infection,  such  as  chronic  intestinal  stasis,  produces  a  chronic 
toxaemia,  to  which  that  from  the  kidney  is  added.  In  other  cases  the  kidney 
is  the  principal  or  only  source  of  the  toxaemia.  Nephrectomy  is  the  only 
effective  treatment  in  the  latter  class,  and  is  frequently  a  difficult  and  dangerous 
operation. 

In  some  cases  of  chronic  pyelocystitis  the  principal  focus  of  infection  lies 
in  the  prostate.  In  such  cases  the  symptoms  are  principally  those  of  cystitis  ; 
the  pyelitis  passes  off  after  a  slight  preliminary  attack,  or  persists  in  a  mild 
form.  Recovery  depends  upon  successful  treatment  of  the  chronic  prostatitis. 
The  prognosis  for  ultimate  recovery  is  somewhat  better  in  these  cases,  but  in 
some  the  condition  persists  in  spite  of  vigorous  and  prolonged  treatment. 


PYLORUS.     CONGENITAL     STENOSIS     OF  439 


Chronic  pyelocystitis  may  be  complicated  by  stone  in  the  kidney  or  bladder, 
by  movable  kidney,  diverticulum  of  the  bladder,  stricture,  or  enlarged  prostate, 
or  by  bladder  growths.  The  prognosis  in  such  cases  depends  upon  the  possi- 
bility of  removal  of  the  stone  or  other  complicating  disease.  Until  this  is 
done  the  pyelocystitis  cannot  be  cured. 

Two  special  forms  of  B.  coli  pyelocystitis  may  be  mentioned.  The  pyelitis 
of  infancy  and  childhood  is  a  frequent  form.  It  occurs  in  infants  a  few  months 
old  and  in  young  children,  and  takes  an  acute  course.  The  condition  occasion- 
ally ends  fatally,  but  recovery  takes  place  in  the  great  majority  of  cases,  even 
when  a  very  high  temperature  is  recorded,  and  profound  toxaemia,  even  coma, 
is  present.  The  cases  improve  rapidly  under  treatment  ;  the  temperature 
falls,  and  the  symptoms  subside  in  a  week  or  ten  days.  The  pus  may  remain 
for  several  weeks,  and  the  bacteria  for  longer,  but  eventually  these  also 
disappear. 

Pyelonephritis  is  a  not  infrequent  complication  of  the  early  months  of 
pregnancy,  arising  usually  in  a  previously  healthy  urinary  tract,  but  occasion- 
ally as  an  exacerbation  of  a  chronic  pyelocystitis.  Premature  labour  occurs 
in  25  per  cent  of  severe  cases.  When  the  acute  attack  occurs  early  in  pregnancy, 
and  there  is  an  interval  of  normal  temperature  before  parturition  takes  place, 
the  puerperium  is  usually  apyretic.  If,  however,  the  acute  attack  occurs  late 
in  pregnancy,  there  is  usually  fever  during  the  puerperium  ;  but  puerperal 
infection  does  not  occur. 

If  the  pregnancy  be  interrupted,  the  child  is  usually  ill-nourished,  and  dies 
in  one-third  of  the  cases.  If  the  attack  occur  late,  and  the  pregnancy  go  on  to 
full  term,  the  child  is  usually  healthy  and  well-nourished. 

The  production  of  abortion,  or  the  induction  of  premature  labour,  is  seldom 
necessary,  but  it  may  be  called  for  in  a  severe  case.  After  parturition,  the 
pyelonephritis  may  subside,  and  the  urine  may  clear  and  become  sterile  ;  but 
more  frequently  bacilluria  and  some  degree  of  pyelonephritis  persist,  and 
exacerbation   occurs   during   succeeding  pregnancies.  /.  W.  Thomson  Walker. 

PYELONEPHRITIS {See  Pyelocystitis.  ) 

PYLORUS,  CONGENITAL  STENOSIS  OF  {see  also  Stomach,  Surgical 
Affecions  OFj.^ — Though  rather  new  to  the  profession,  this  disease  is  by  no 
means  a  rarity.  The  large  proportion  of  cases  recognized  in  the  first-born 
infants  of  medical  men  makes  it  probable  that  a  number  of  deaths  occur  in 
other  children  without  a  diagnosis.  The  hall-mark  of  the  condition  is  the 
association  of  vomiting  with  constipation,  palpable  pyloric  tumour,  and  visible 
gastric  peristalsis.  The  symptoms  usually  come  on  at  the  age  of  about  four 
weeks,  and  apart  from  treatment  are  fatal  in  a  few  weeks. 

It  is  still  hotly  debated  whether  the  treatment  ought  to  be  purely  medical  or 
purely  surgical.  Scudder,  for  instance,  denies  that  any  cures  have  ever  been 
effected  by  medical  means,  and  urges  operation  in  every  case. 

Results  of  Medical  Treatment. — Medical  treatment  includes  lavage,  careful 
feeding  by  the  best  modern  methods  (including  citrated  milk,  peptonized  milk, 
albumin  water,  or  breast  milk,  all  in  small  quantities),  and  perhaps  a  little  tincture 
of  opium.  There  is  no  doubt  that  many  cases  have  recovered  under  such  treat- 
ment. The  proportion  varies  in  different  statistics  from  10  to  60  per  cent  ;  it  is 
probably  less  than  half  the  total  number.  Monier's  figures  give  80  to  90  per  cent 
of  fatalities  under  medical  treatment. 

In  any  individual  case,  the  prognosis  depends  upon  the  following  factors. 
Children   of   8  lb.   do  better  than  those  of  6  lb.     Diarrhoea  is  very  ominous. 


44° 


INDEX     OF    PROGNOSIS 


Head-retraction  and  fever  may  be  seen  just  before  death.  Large  vomits  are 
apt  to  induce  fatal  collapse.  If  the  weight  continues  to  fall  and  the  vomiting 
persists  after  two  to  three  weeks  of  careful  medical  treatment,  it  is  not  Ukely 
that  the  child  will  hve,  apart  from  operation. 

It  must  be  remembered  that  the  small  intestine  is  thin  and  atrophic,  and  any 
attempt  to  '  feed  up  '  the  child,  before  or  after  operation,  wiU  probably  induce 
fatal  diarrhoea. 

In  favourable  cases  treatment  takes  six  to  twelve  weeks.  The  tumour  is 
probably  permanent  :  in  cases  described  by  Batten  and  many  others,  the  persis- 
tence of  the  hjrpertrophy  was  verified  by  autopsy  long  after  more  or  less  perfect 
cure  of  the  symptoms. 

There  is  some  tendency  to  relapse  in  later  life  ;  Scudder  quotes  a  number  of 
authorities  to  this  effect. 

Results  of  Surgical  Treatment. — From  1898  to  1905  the  results  of  surgical 
treatment  were  not  very  good,  but  probably  better  than  those  obtained  by 
medical  means.  According  to  Scudder,  the  mortahty  of  operation  was  46-5  per 
cent.  Paterson  in  1906  collected  the  records  of  25  cases  treated  by  gastro- 
jejunostomy, of  which  13  died  of  the  operation,  3  died  \^dthin  two  months,  and 
9  were  cured.  Pyloroplasty  was  more  successful  :  of  9  recorded  cases,  3  died 
of  the  operation,  i  died  two  months  later  of  diarrhoea,  and  5  were  cured. 

Since  1905,  three  short  series  have  been  pubUshed  by  Scudder  showdng  much 
better  results.  These  include,  first,  10  cases  operated  on  by  several  surgeons 
on  the  Pacific  coast,  and  recorded  by  Stillman  ;  second,  a  group  of  9  in  the  practice 
of  Richter,  of  Chicago  ;  and  third,  Scudder's  own  series  of  17  operations.  These 
combined  give  a  record  of  36  cases,  with  only  5  deaths — that  is,  a  mortahty  of 
i3'8  per  cent.  These  American  cases  were  treated  by  gastrojejunostomy. 
Scudder's  patients  have  been  followed  for  periods  varying  from  one  to  eight 
years  (all  over  two  years,  -with  a  single  exception) .  All  but  three  were  under 
eight  weeks  old  at  the  time  of  the  operation. 

The  difference  in  the  mortahty  before  and  since  1905  is  due  partly  to  improved 
technique,  but  no  doubt  principally  to  the  fact  that  in  the  older  series  the  surgeon 
was  called  in  when  the  infant  was  already  greatly  reduced  after  the  failure  of 
medical  means,  whereas  the  American  surgeons  quoted  above  would  operate  as 
soon  as  the  diagnosis  was  made,  wdthout  waiting  to  see  the  results  of  dieting, 
lavage,  and  so  forth.  We  consider,  personally,  that  a  fortnight  is  a  suitable 
period  during  which  to  try  medical  means. 

Results  of  Operation  for  Congenital  Pyloric  Stenosis. 


Keporter 

Cases 

Died  ol         Died 
operation        later 

i 

Cured 

^ft^f.l°'i J  Gastrojejunostomy     - 
Scudder's  three  series    since  1905 

25 
9 

36 

13              3 
3      1        1 

5       1         0 
1 

9 

5 

31 

Apparently  the  operation  does  not  lead  to  any  reduction  in  the  mass  of  the 
pyloric  muscle.  A  baby  operated  on  by  Murphy  recovered  well  from  the 
operation,  but  died  six  and  a  half  months  later  from  causes  unconnected  ■with 
the  gastric  trouble  :  the  tumour  of  the  pylorus  persisted  unchanged.  Scudder 
states  that  in  nine  cases  after  a  gastrojejunostomy  in  these  infants,  bismuth 
skiagraphy  showed  that  the  food  passed  through  the  stoma  and  not  through 


PYONEPHROSIS  44 1 


the  pylorus  :  it  is  well  known  that  the  food  passes  only  through  the  normal 
passage  and  not  by  the  stoma  after  a  short-circuiting  operation  in  patients  or 
animals  with  no  pyloric  obstruction  ;  evidently,  therefore,  the  mechanical 
obstruction  of  the  circular  muscle  persists. 

After  successful  operation,  the  children  grow  up  into  normal  individuals.  A 
very  sturdy  boy,  aged  four,  on  whom  gastrojejunostomy  was  performed  in  his 
second  month,  is  known  to  the  writer. 

To  summarize,  we  may  conclude  on  the  evidence  before  us  that  medical 
treatment  will  save  certainly  less  than  half  the  patients,  perhaps  so  few  as  10  per 
cent,  and  that  the  survivors  may  suffer  from  persistent  symptoms  of  pyloric 
obstruction  ;  that  the  operation-mortality  in  early  cases  is  less  than  20  per  cent, 
but  may  be  50  per  cent  if  medical  treatment  has  been  persisted  in  before  the 
surgeon  is  called  ;  and  that  neither  medical  nor  surgical  treatment  leads  to  any 
improvement  in  the  pyloric  hypertrophy. 

References. — Miller,  Medical  Diseases  of  Children,  igii,  260  ;  Paterson,  Lancet, 
1906,  i,  577  ;    Scudder,  Ann.  Surg.  1914,  lix,  239.  a.  Rendle  Shnrt. 

PYONEPHROSIS, — There  are  two  types  of  pyonephrosis,  and  the  prognosis 
is  different  in  each.  The  first  type  is  pyonephrosis  secondary  to  uronephrosis 
(hydronephrosis),  or  uropyonephrosis  ;  the  second  is  pyonephrosis  developing 
from  acute  pyelonephritis. 

In  uropyonephrosis  the  condition  is  unilateral,  and  the  actual  obstruction 
is  situated  high  up  in  the  ureter,  being  due  to  a  stricture,  stone,  or  duplication 
of  the  ureter.     The  superadded  infection  is  usually  haematogenous. 

Pyonephrosis  developing  in  pyelonephritis  occurs  especially  in  cases  of  old- 
standing  disease  of  the  lower  urinary  organs,  such  as  stricture,  chronic 
prostatitis,  enlarged  prostate,  growths  of  the  bladder,  etc.  There  is  frequently 
bilateral  disease,   but  the  second  kidney  is  not  necessarily  pyonephrotic. 

The  general  S5^mptoms  of  uropyonephrosis  are  often  moderate,  although 
in  some  cases  the  character  of  the  illness  resembles  that  of  the  other  form  of 
pyonephrosis. 

In  pyonephrosis  due  to  pyelonephritis,  the  patient  is  seriously  ill,  with  a 
high  swinging  temperature  and  other  symptoms  of  toxaemia.  Unrelieved 
pj'onephrosis  may  lead  to  a  fatal  result  in  ten  or  fourteen  days  ;  or  the  course 
may  be  more  prolonged,  and  the  pus  find  its  way  through  the  wall  of  the  sac 
and  form  a  perinephritic  abscess,  death  taking  place  from  exhaustion  after 
some  weeks. 

The  prognosis  depends  upon  the  patient  obtaining  prompt  relief  by  opera- 
tion, and  upon  the  presence  or  absence  of  infection  of  the  bladder  and  of  the 
second  kidney.  In  a  few  cases  where  a  mild  infection  of  a  hydronephrotic 
sac  has  occurred,  it  is  possible  to  do  a  plastic  operation  for  removal  of  the 
obstruction,  and  what  remains  of  the  kidney  is  saved.  In  the  majority  of  cases, 
however,  the  choice  lies  between  nephrotomy  and  nephrectomy. 

Nephrotomy  can  be  performed  in  the  very  worst  cases  when  the  patient  is 
weak  from  prolonged  suppuration,  and  in  cases  where  it  is  impossible  to  esti- 
mate the  value  of  the  remaining  kidney,  or  when  this  organ  is  known  to  be 
the  seat  of  advanced  disease.  The  mortality  of  this  operation  is  from  17 
(Kiister)  to  23  per  cent  (Tuffier).  After  the  operation  an  improvement  in  the 
work  of  the  second  kidney  is  usually  observed,  and  the  general  health  greatly 
improves.     In  27  per  cent  of  cases  the  sac  shrinks  and  the  patient  is  cured. 

In  a  certain  number  of  cases  septicaemia  persists,  and  the  work  of  the  second 
kidney  is  still  poorly  performed.  This  is  due  to  continued  suppuration  in 
the  thick  fibrous-walled  cavity,  to  undrained  pouches,  to  abscesses  in  the  walls 


442  INDEX     OF    PROGNOSIS 

and  partitions,  to  stones  being  left  in  the  sac  (i6  per  cent  of  cases),  or  to  the 
persistence  of  the  ureteric  block.  A  fistula  remains  in  from  45-6  per  cent 
(calculous  pyonephrosis  34-2  per  cent,  non-calculous  pyonephrosis  57-1  per 
cent)  to  56  per  cent  (Kiister). 

Secondary  nephrectomy  is  indicated  when  septicaemia  persists  ;  when  it  is 
believed,  from  the  inadequate  secretion  of  the  diseased  kidney  and  the  ab- 
sence of  disease  in  the  second  kidney,  that  a  depressed  renal  function  in  the 
latter  will  improve  after  nephrectomy ;  and  when  the  patient  is  gradually 
losing  ground  from  prolonged  suppuration.  The  mortaUty  of  secondar};- 
nephrectom.y  is  only  5-9  per  cent.  If  this  be  added  to  the  mortalit^^  of 
nephrotomy  (23-3  per  cent),  the  total  mortality  of  nephrotomy  followed  by 
nephrectomy  at  a  later  date  is  29-2  per  cent. 

Primary  nephrectomy  should  be  performed  when  it  is  certain,  from  examina- 
tion of  the  urine  of  the  second  kidney,  that  the  function  of  this  organ  is 
adequate.     The  mortality  of  this  operation  is  17  per  cent. 

The  prognosis  after  nephrectomy,  in  cases  where  the  second  kidney  and  the 
bladder  are  healthy,  is  very  good,  and  there  is  no  reason  to  expect  that  the 
duration  of  life  \vill  be  shortened.  On  the  other  hand,  in  cases  where  there 
is  chronic  cystitis  which  does  not  clear  up  after  nephrectomy,  and  especially 
where  the  second  kidney  is  already  infected,  the  danger  of  acute  pyelonephritis 
of  the  remaining  kidney,  with  suppression  of  urine,  is  very  considerable.  Even 
if  this  take  place,  however,  the  outlook  is  not  hopeless.  The  writer  has  per- 
formed nephrotomy  on  the  solitary  kidney  in  such  a  case,  and  the  patient  is 
known  to  be  alive  and  in  fair  health  several  years  after. 

/.  W.  Thomson  Walker. 

PYOSALPINX.— (See  Salpingitis.) 

RECTAL  PROLAPSE.— In  young  children,  the  great  majority  of  cases  of 
prolapse  of  the  bowel  get  well  in  the  course  of  a  few  months  with  simple 
treatment  (replacement,  purgatives,  astringent  lotions,  etc.).  It  is  not  possible 
to  quote  exact  statistics.  It  is  only  in  a  few  instances  that  any  operation  is 
required. 

In  adults,  on  the  other  hand,  there  is  little  tendency  to  amendment,  and 
operation  will  be  necessary.  Paraffin  injection  is  going  out  of  fashion  ;  although 
it  may  be  immediately  successful,  cases  of  ischiorectal  abscess  have  been  recorded 
at  a  long  interval  afterwards.  When  only  the  mucous  coat  prolapses,  searing 
it  to  the  muscle  with  the  cautery  is  very  successful.  Severe  cases  require 
excision,  and  this  is  usually  satisfactory,  though  temporary  incontinence  may 
follow  ;  this  nearly  always  gets  well  at  last.  In  a  few  rare  cases  colopexy  is 
necessary  ;  this  is  well  spoken  of  ;  no  doubt  failure  is  very  rare,  but  the 
writer  has  seen  a  case.  A.  Rendle  Short. 

RECTUM,  CANCER  OF. — Prognosis  in  carcinoma  of  the  rectum  largely 
depends  on  the  stage  at  which  the  disease  is  detected.  In  this  connection  it  is 
impossible  to  insist  too  strongly  upon  the  importance  of  a  digital  examination 
of  the  rectum  in  every  patient,  whatever  his  age,  presenting  rectal  symptoms. 
It  must  be  borne  in  mind  that  rectal  cancer  may  occasionally  occur  as  early  as 
the  second  decade  of  hfe.  A  cylindrical-celled  carcinoma  of  the  rectum  has 
been  recorded  in  a  girl  of  eleven,  the  youngest  case  of  carcinoma  on  record. 

Cancer  of  the  rectum  begins  upon  one  aspect  of  the  bowel  wall  as  a  small 
ulcer,  which  spreads  circularly  both  along  and  across  the  bowel.  As  it  spreads 
it  puckers  up  and  contracts  the  affected  area  of  the  mucosa,  and  thus  strictures 
the  bowel.     Accordingly  intestinal  obstruction  or  perforation  is  the  usual  cause 


RECTUM,     CANCER     OF 


443 


of  death  in  untreated  cancer  of  the  rectum.  Even  when  a  well-defined  stricture 
has  formed,  a  bridge  of  normal  mucosa  can  still  be  detected  forming  part  of  the 
circumference  of  the  stricture,  and  the  breadth  of  this  bridge  gives  some  idea 
of  the  stage  which  the  cancerous  ulcer  has  reached.  Even  more  important  is 
it  to  determine  whether  the  growth  has  passed  outside  the  walls  of  the  rectum. 
If  the  growth  is  fixed  to  its  surroundings,  this  is  probably  the  case.  The  vertical 
extent  of  the  growth  in  the  axis  of  the  rectum  is  a  less  important  point.  It  used 
to  be  considered  that  a  rectal  growth  was  only  operable  if  the  examining  finger 
could  pass  through  the  stricture  and  feel  normal  mucosa  above.  With  modern 
methods,  extension  of  the  growth  along  the  bowel  for  a  considerable  distance 
is  not  in  itself  a  bar  to  operation. 

It  must  be  remembered  that  methods  of  estimating  the  operabilitj^  of  a  growth 
from  local  examination  only  are  open  to  fallacy.  In  certain  cases,  while  the 
primary  growth  is  still  small  and  mobile,  metastases  may  form  in  the  hver, 
probably  owing  to  cells  carried  there  by  the  blood-stream.  On  the  other  hand, 
fixation  of  the  growth  may  result  from  merely  inflammatory  changes.  A  final 
estimate  as  to  the  operabiUty  of  a  rectal  carcinoma  can  only  be  given  when  the 
abdomen  has  been  opened  and  its  interior  examined  manually.  This  is  one  of 
the  advantages  which  the  combined  abdomino-perineal  operation  possesses 
over  other  methods. 

Since  most  cases  of  cancer  of  the  rectum  occur  in  advanced  hfe,  the  general 
condition  of  the  patient's  health — and  more  especially  the  condition  of  the  heart 
and  kidneys — is  an  important  element  in  the  prognosis.  Unless  their  vital  organs 
are  fairly  sound,  patients  cannot  be  expected  to  tolerate  an  operation  for  the 
extirpation  of  the  growth.  On  the  other  hand,  apparently  delicate  patients, 
if  free  from  organic  disease,  often  withstand  severe  operations  well.  The  worst 
subjects  apart  from  organic  disease  are,  in  my  experience,  of  the  stout  florid 
type  with  soft  tissues,  especially  if  alcohol  has  been  habitually  indulged  in. 

Prognosis  as  regards  Recovery  from  Radical  Operation. — The  follo\\'ing 
table  by  Tuttle,  quoted  by  Swinford  Edwards,  gives  the  mortality  of  the  different 
methods  of  operation  up  to  the  date  of  its  pubhcation  : — 

Mortality  of  the  Various  Operations 


FOR 

Rectal  Cancer. — {Tuttle.) 

Method 

Xumber 
of  Cases 

Deaths 

Jlortality 

Sacral 
Perineal 
Abdominal 
Combined 

913 

569 
49 
22 

211 
76 

18 
9 

per  cent 

23-1 
13-5 
3(;7 
40-9 

These  figures  show  a  high  mortality  for  all  methods  except  the  perineal.  At 
the  present  time  they  do  not  afford  a  correct  view  of  the  risk  involved  in  the 
abdomino-perineal  method,  a  risk  which  by  improved  technique  is  reducible, 
as  I  shall  be  able  to  show,  to  a  fraction  over  15  per  cent.  In  my  opinion,  with 
rare  exceptions,  and  possibly  excluding  squamous-celled  growths  beginning  in 
the  anal  region,  the  only  two  operative  procedures  worth  considering  in  cancer 
of  the  rectum  are  :  first,  abdomino-perineal  excision  of  the  rectum  with  the 
formation  of  a  colostomy  ;    second,  simple  colostomy. 

This  view  excludes  the  possibility  of  retaining  the  natural  faecal  outlet  at  the 
anus,  an  end  very  desirable  in  itself.     But  attempts  to  bring  down  the  upper 


444  INDEX    OF    PROGNOSIS 

colon  and  attach  it  to  the  sphincters  are  very  dangerous  to  hfe.  The  mortality 
of  an  abdomino-perineal  excision  terminated  by  bringing  down  the  bowel  is  at 
least  double  that  of  the  same  operation  terminated  by  a  colostomy.  Even  if 
the  patient  survives  the  operation,  the  anal  sphincters  may  subsequently  be- 
come fibrotic  and  useless.  The  danger  of  recurrence  of  the  growth  in  the  anal 
structures  left  behind  is  also  a  very  real  one.  In  most  cases,  too,  the  final  result 
is  a  sacral  anus,  owing  to  the  breaking  down  of  part  of  the  hne  of  union  of  the 
bowel. 

But  what  of  excisions  of  the  rectum  performed  from  below  ?  While  some 
surgeons,  notably  Mr.  Harrison  Cripps,  have  recorded  satisfactory  results  in  a 
considerable  number  of  cases,  others,  especially  Mr.  W.  Ernest  Miles,  have 
experienced  recurrence  in  almost  every  case.  My  own  experience  of  these 
operations  accords  with  that  of  Mr.  Miles.  But  it  has  not  been  my  good  fortune 
to  meet  with  early  cases,  where  the  growth  is  a  small  one  and  well  localized  to 
one  portion  of  the  bowel  wall.  In  such  cases  some  competent  authorities, 
e.g.,  Mr.  Lockhart  Mummery,  would  advocate  perineal  excision.  I  agree  with 
Mr.  Mummery  that  very  stout  patients,  those  with  impaired  constitutions,  and 
those  over  seventy  years  of  age,  are  unsuitable  subjects  for  the  abdomino- 
perineal operation.  In  such  cases  I  should  perform  a  simple  colostomy.  But 
even  in  small  early  growths,  if  the  patient  is  a  suitable  subject,  I  should  advocate 
the  complete  operation ;  for  it  is  known  that  glandular  involvement  may 
occur  when  the  local  growth  is  still  in  an  early  stage,  and  the  abdomino-perineal 
operation  is  the  only  procedure  by  which  reasonable  security  can  be  attained. 

As  regards  immediate  risk,  the  perineal  operation  is  undoubtedly  the  safer 
procedure  at  present.  But  as  the  combined  operation  is  being  rapidly  improved, 
I  anticipate  that  its  mortality  will  soon  fall  to  lo  per  cent.  Mr.  Cripps's 
mortality  for  perineal  excision  is  8  per  cent  (3  deaths  in  38  cases).  Mr.  Miles, 
among  26  cases  of  the  abdomino-perineal  operation,  lost  10,  a  mortality  of 
38  per  cent.  The  same  operation,  perhaps  however  on  rather  more  restricted 
lines,  shows  in  my  own  hands  a  mortality  of  2  among  13  cases,  excluding  a 
fatal  case  in  which  a  large  fibroid  uterus  was  removed  at  the  same  time.  Only 
one  death  occurred  in  the  first  ten  cases,  a  result  mainly  due,  I  believe,  to  the 
method  of  post-operative  saline  infusion  which  I  advocate.  My  present  mortahty 
thus  works  out  at  only  15  per  cent,  a  figure  which  is  not  unsatisfactory. 

My  experience  shows  that  the  abdomino-perineal  operation,  though  neces- 
sarily a  severe  one,  is  fairly  safe  when  performed  under  favourable  conditions. 
Age  is  not  a  bar  to  it,  for  my  series  of  successful  cases  includes  two  patients 
over  sixty  years  of  age.  It  must  be  preceded  by  a  careful  preparation  of  the 
patient,  with  the  object  of  rendering  the  lower  bowel  as  aseptic  as  possible  and 
of  increasing  his  resisting  power  to  micro-organisms.  For  this  latter  purpose 
the  prophylactic  use  of  vaccines  is  advisable.  The  operation  should  never  be 
done  except  in  a  fully  equipped  operating  theatre  and  in  the  operator's  familiar 
surroundings.  If  this  rule  is  broken,  minor  contretemps  will  sooner  or  later 
occur,  which  in  such  an  operation  may  have  serious  consequences. 

Prognosis  as  regards  Recurrence  after  Operation. — The  published  results  of 
Mr.  Ernest  Miles  show  the  prognosis  of  different  methods  of  operation  in  the 
hands  of  the  same  surgeon.  They  are  a  convincing  testimony  to  the  superiority 
of  abdonrino-perineal  over  perineal  operations. 

In  his  search  for  the  ideal  method,  Mr.  Miles  has  passed  through  various  stages. 
He  describes  how,  between  1889  and  1900,  he  did  operations  from  the  perineum, 
with  section  of  the  bowel  one  inch  above  the  margin  of  the  growth.  These 
operations  were  followed  by  recurrence  in  an  average  period  of  twelve  months. 
During  1902  to  1904  he  performed  fourteen  operations  with  a  wider  removal  of 


RECTUM,     CANCER     OF  445 

the  perineal  skin  and  the  ischiorectal  fat,  the  operation  otherwise  remaining 
the  same.  Recurrence  took  place  in  every  case,  and  was  most  common  in  the 
levator  ani.  In  a  third  series  of  eleven  cases,  1904-5,  Kraske's  method  was 
adopted  ;  the  mesorectum  and  the  levatores  ani  were  extirpated,  and  the  bowel 
was  divided  three  inches  above  the  uppermost  limit  of  the  growth.  Recurrence 
took  place  in  every  instance,  and  seven  of  the  recurring  growths  involved  the 
lower  margin  of  the  bowel  and  the  adjacent  mesocolon.  As  Miles  remarks, 
these  recurrences  probably  arose  either  from  pre-existing  permeation  of  the 
apparently  healthy  rectal  wall,  or  from  metastases  in  the  paracolic  lymph  nodes 
— that  is  to  say,  the  disease  returned  in  tissues  situated  above  the  field  of 
operation.  He  accordingly  decided  to  excise  as  much  of  the  pelvic  colon  and 
its  mesocolon  as  he  could  reach.  After  this  operation  recurrence  followed  in 
every  case,  and  in  fourteen  cases  it  took  place  in  the  pelvic  peritoneum  and  the 
pelvic  mesocolon — tissues  which  could  not  be  removed  by  an  operation  performed 
entirely  from  below.  Miles  accordingly  abandoned  the  perineal  method  ;  he 
had  performed  it  successfully  in  58  patients,  of  whom  55  were  known  to  have 
suffered  from  recurrence,  a  percentage  of  return  of  94-82  per  cent.  Since 
abandoning  the  perineal  operation  Miles  has  developed  an  abdomino-perineal 
method,  which  in  many  details  is  his  own.  He  has  done  this  operation  42  times, 
with  a  mortality  of  40  per  cent.  The  operation  would  appear  from  his  statistics 
to  be  unjustifiable  after  the  age  of  sixty,  since  no  patients  who  submitted  to  it 
beyond  that  age  recovered  from  it.  Among  the  25  patients  who  have  survived 
the  operation,  only  4  have  had  recurrence  of  their  disease.  At  the  present 
time  19  patients  are  living,  and  10  of  them  have  survived  the  operation  more 
than  two  years  without,  up  to  now,  showing  any  sign  of  recurrence.  These 
results  are  a  brilliant  advance  on  any  that  have  been  hitherto  pubhshed. 

Among  my  own  1 1  cases  who  survived  the  operation,  i  is  living  live  years  later 
but  has  recently  developed  signs  of  recurrence,  and  i  died  of  her  disease  about 
a  year  after  the  operation.  The  other  9  are  alive  and  well,  so  far  as  I  know  ; 
one  is  doing  full  work  as  foreman  at  a  lead  works,  another  as  a  policeman  ; 
four  of  them  have  been  seen  or  heard  from  recently.  Most  of  my  cases  are  too 
recent  to  claim  as  successes,  but  the  results  to  date  are  satisfactory.  A  final 
judgement  on  the  abdomino-perineal  operation  will  not  be  possible  for  some 
years,  but  its  superiority  over  the  older  methods  is  already  established. 

Mr.  Lockhart  Mummery,  in  his  recent  work,  quotes  the  following  percentages 
of  three-year  cures  following  the  perineal  methods  of  operation  :  Harrison 
Cripps  25  per  cent,  Hochenegg  17-2  per  cent,  Tuttle  14-8  per  cent.  These 
figures  were  no  doubt  obtained  by  a  selection  of  cases  far  more  rigid  than  is 
now  applied,  a  fact  which  must  be  borne  in  mind  as  increasing  the  advantage 
shown  by  the  combined  method. 

Influence  of  Radium  Treatment  on  Prognosis. — The  value  of  radium  in  cancer 
of  the  rectum  is  not  yet  determined,  but  Wickham  and  Degrais  (1913)  state  that 
inoperable  cases  of  cancer  of  the  rectum  have  certainly  found  in  radium  a 
palliative  and  useful  treatment,  that  radiation  may  clear  the  passage  by 
dissolving  the  nodules,  that  the  haemorrhage,  discharge,  and  pain  diminish,  and 
that  the  general  condition  of  the  patient  consequently  improves.  In  two  cases 
they  were  able  to  avert  a  colostomy,  and  to  prolong  a  tolerable  existence  for 
periods  of  twelve  and  fifteen  months  respectively. 

It  is  obvious  that  the  subject  has  not  yet  reached  a  stage  in  which  general 
statements  are  possible,  and  in  any  particular  case  the  results  of  treatment  are 
uncertain.  A  case  of  my  own  shows  that  radium  may  convert  an  inoperable 
into  an  operable  case.  The  patient,  a  man  of  sixty,  was  pronounced  beyond 
the  range  of  operation  by  a  well-known  surgeon,  and  was  brought  to  me  for  a 


446  INDEX     OF     PROGNOSIS 

second  opinion.  I  agreed  that  the  case  was  inoperable,  and  advised  a  trial  of 
radium.  The  treatment  was  carried  out  by  Dr.  N.  Finzi.  Within  a  few  weeks 
the  edges  of  the  growth  became  flat  and  fibrotic,  so  that  it  might  have  been 
mistaken  for  a  simple  stricture  ;  shght  mobility  could  now  be  detected  in  it. 
I  then  advised  and  carried  out  an  abdomino-perineal  radical  operation.  Two 
tubes  of  radium  were  inserted  at  the  operation  into  the  pelvic  cavity,  one  from 
below  aiid  one  from  above.  The  peritoneum  forming  the  floor  of  the  recto- 
vesical pouch  was  intected,  and  the  operation  was  here  necessarily  an 
incomplete  one.  Whether  as  a  radium  effect  or  not,  suppuration  occurred  in 
the  pelvis,  and  during  convalescence  a  troublesome  attack  of  pyehtis  occurred  ; 
but  at  present,  a  year  later,  the  patient  remains  well  and  free  from  recurrence. 

Cases  suitable  for  Colostomy. — In  a  very  large  proportion  of  the  cases  unsuit- 
able for  radical  operation,  an  immediate  colostomy  is  the  proper  line  of  treat- 
ment. The  operation  should  not  be  deferred  until  obstruction  is  imminent.  As 
Mr.  Swinford  Edwards  says  :  "  That  I  would  perform  a  colostomy  on  every 
patient  upon  whom  I  had  decided  that  a  radical  operation  was  inadmissible  I 
will  not  say,  but  rather  that  I  would  strongly  advise  the  operation  as  soon  as 
any  of  the  symptoms  of  the  disease  became  so  marked  as  to  interfere  -with  the 
comfort  of  the  patient."  This  statement,  in  my  opinion,  rather  underestimates 
the  importance  of  colostomy.  The  operation  is  not  merely  a  means  of  increasing 
the  patient's  comfort  ;  it  appears  to  exercise  a  definite  influence  in  retarding 
the  progress  of  the  disease. 

Prognosis  after  Colostomy. — The  prognosis  in  cases  of  cancer  of  the  rectum 
treated  by  a  simple  colostomy  is  much  more  hopeful  than  is  generally  believed. 

First,  in  regard  to  the  question — Is  life  worth  living  with  a  colostom}^  wound  ? 
Upon  this  point  most  patients,  and  some  medical  men,  are  apt  to  take  quite 
unjustifiably  gloomy  views.  Numbers  of  people  with  a  colostomy  opening  go 
about  their  daily  work,  and  are  to  all  appearance  normal  individuals.  Thus,  a 
well-known  police  magistrate  with  this  disabihty  sat  on  the  bench  for  some 
years  ;  among  patients  of  my  own,  one  is  foreman  at  a  factory,  another  a  police 
constable  doing  full  duty,  another  a  dressmaker  who  makes  frequent  Continental 
journeys  in  the  course  of  her  business.  There  are  two  conditions  essential 
to  a  successful  colostomy,  one  that  the  opening  shall  be  well  situated  (preferably 
in  the  midst  of  the  rectus  muscle)  and  properly  made,  the  other  that  it  shall  be 
properly  managed  by  the  patient.  An  injection  of  soap  and  water,  followed 
by  the  use  of  the  bed-pan  before  rising  in  the  morning,  will  usually  ensure 
freedom  from  trouble  during  the  day.  Care  must  also  be  exercised  by  the 
patient  in  regard  to  diet,  and  laxative  foods  must  be  taken  in  strictly  regulated 
quantities. 

Having  considered  prognosis  with  regard  to  comfort,  we  may  turn  to  the 
outlook  in  regard  to  the  symptoms  of  the  growth  and  its  rate  of  advance.  The 
diversion  of  the  septic  stream  of  faeces  from  the  surface  of  the  ulcer  is  followed 
in  practically  all  cases  by  a  diminution  or  cessation  of  niucopurulent  discharge 
from  its  surface.  Accordingly,  the  teasing  diarrhoea  or  rectal  tenesmus  produced 
by  the  irritant  discharge  diminishes  or  ceases,  especially  if  the  lower  bowel  is 
periodically  washed  out  through  the  colostomy  wound  with  a  mild  antiseptic 
such  as  boracic  lotion.  There  is  a  corresponding  improvement  in  the  bleeding, 
and,  except  in  very  advanced  cases,  in  the  sacral  pain,  for  both  of  these  signs 
are  mainly  of  septic  origin.  For  some  years  the  patient  may  be  able  to  forget 
that  the  growth,  though  quiescent,  is  still  present.  Sooner  or  later,  however, 
sciatic  pains  will  indicate  infiltration  around  the  sacral  plexus,  and  frequency 
of  micturition,  with  albuminuria  and  hsematuria,  will  indicate  invasion  of  the 
bladder.     Compression   of   the   ureters   will   be   followed   by   ascending   pyelo- 


RHEUMATIC     FEVER  447 

nephritis,  which  is  likely  to  end  the  case  if  in  the  meantime  hepatic  metastases 
do  not  manifest  themselves. 

The  period  of  relief  from  symptoms  which  follows  a  colostomy  varies  widely. 
It  may  be  estimated  at  from  one  to  five,  or  even  seven,  years.  In  one  case 
within  my  knowledge  a  simple  colostomy  was  followed  after  some  years  by 
complete  cicatrization  of  the  growth,  spontaneous  closure  of  the  colostomy,  and 
re-establishment  of  the  natural  anal  evacuations — an  instance  of  the  natural 
cure  of  cancer :  it  is  probable,  however,  that  in  this  case  the  disease  will 
ultimately  re-assert  itself. 

While  a  properly  made  and  managed  colostomy  wound  need  give  little  more 
trouble  than  a  set  of  artificial  teeth,  an  ill-made  prolapsed  one,  with  colitis  of 
the  bowel  above  and  sepsis  about  the  opening,  is  undoubtedly  a  misery  to 
which  some  patients  will  consider  death  preferable.  w.  Sampson  Handley. 

RELAPSING  FEVER. — There  are  now  known  to  be  at  least  three,  or  probably 
more,  species  of  spirochaetes  causing  fever  of  the  relapsing  type — Indian, 
European,  and  African  (African  tick  fever).  Where  the  treatment  is  purely 
symptomatic,  the  mortality  is  mainly  due  to  complications,  particularly 
pulmonary  ones,  though  the  septicaemic  nature  of  the  disease  may  cause  death. 

The  various  epidemics  have  differed  in  the  mortality.  In  Bombay,  Vandyke 
Carter  gave  the  mortality  as  iS  per  cent,  and  Choksy  in  the  same  city  from 
1898  to  1907  gives  an  average  mortality  in  9,275  cases  of  30-6  per  cent.  A  much 
lower  mortality  has  been  recorded  in  Northern  India  ;  and  with  the  other  forms 
of  relapsing  fever  found  in  Egypt,  Russia,  Ireland  (famine  fever),  and  Africa 
(African  tick  fever),  it  is  only  4  per  cent. 

The  previous  condition  of  the  patient  is  important,  as  those  who  are  badly  fed 
and  in  overcrowded  cities  have  a  higher  mortality  ;  nevertheless  well-fed  and 
well-cared-for  Europeans  may  die  from  the  disease. 

Salvarsan  has  a  marked  effect  on  relapsing  fever,  but  the  number  of  cases 
treated  by  it  has  not  been  large  enough  for  the  effect  on  the  mortality  to  have 
been  adequately  tested.  c.  W.  Daniels. 

RENAL  CALCULUS. —  [See  Kidney  and  Ureter,  Calculus  of.) 

RHEUMATIC  FEVER. — The  prognosis  here  must  depend  upon  the  particular 
organs  that  are  most  affected  in  the  attack.  If  they  are  vital  ones,  such  as  the 
heart  and  brain,  and  are  severely  injured,  the  risk  to  life  is  great  ;  but  where 
the  articulations  chiefly  suffer,  though  there  may  be  great  distress,  the  actual 
danger  to  life  is  small. 

It  is  a  very  difficult  undertaking  in  this  disease  to  single  out  a  particular 
manifestation  and  lay  down  rules  that  apply  to  it  alone,  for  in  the  course  of  the 
illness  we  continually  find  one  lesion  obscuring  the  prognosis  of  another.  There 
still  remains,  however,  a  demand  for  the  prognosis  of  the  individual  lesions, 
and  the  writer  will  accordingly  first  consider,  under  the  general  term 
'  rheumatic  fever,'  the  prognosis  of  the  articular  manifestations. 

There  is  another  difficulty  in  the  prognosis  of  rheumatic  fever  which  is  caused 
by  the  inadequacy  of  the  name.  If  we  use  the  term  rheumatic  fever,  we  discover 
that  the  disease  may  occur  without  fever  in  childhood,  and  that  such  a  lesion  as 
rheumatic  pericarditis  may  be  present  with  a  subnormal  temperature  ;  yet  in 
childhood  also  the  term  acute  rheumatism  is  often  inapplicable,  for  the  onset 
may  be  most  stealthy.  The  condition  most  comparable  to  rheumatism  in  its 
general  course  is  tuberculosis,  for  in  both  there  occur  febrile  and  afebrile  attacks, 
gradual  and  acute  onsets,  and  all  degrees  of  duration. 


448  INDEX     OF     PROGNOSIS 

Fulminating  cases  of  acute  rheumatic  arthritis  are  apparently  not  so  frequent 
as  they  used  to  be.  In  rheumatism,  as  in  gout,  we  do  not  meet  with  so  many 
of  those  cases  from  which  have  been  drawn  the  pictures  of  the  disease  we  read 
in  our  text-books  of  twenty-five  years  ago.  As  Litten  observed,  the  type  of  the 
disease  has  apparently  become  more  septic  in  character. 

The  prognosis  in  these  acute  attacks,  provided  the  heart  is  not  damaged, 
is  good,  and  acute  rheumatic  arthritis  tends  to  complete  recovery. 

Since  the  introduction  of  salicylates,  such  cases  have  been  much  easier  to 
handle  ;  but  when  we  search  for  accurate  facts  upon  the  exact  improvement 
they  have  produced  in  the  prognosis,  we  are  baffled.  There  are  several  im- 
portant reasons  for  this.  On  the  one  hand,  the  frequency  of  some  degree  of 
heart  affection  is  more  generally  realized,  and  the  knowledge  of  the  behaviour 
of  the  disease  in  childhood  is  much  more  definite.  On  the  other  hand,  with 
our  increasing  knowledge,  we  are  getting  milder  cases  under  supervision  more 
readily.  We  have  one  element,  that  of  cardiac  infection,  leading  us  to  think 
that  the  disease  lasts  quite  as  long  as  heretofore,  and  the  other,  the  treatment 
of  the  milder  cases,  leading  us  to  think  that  the  duration  of  the  disease  is 
shortened. 

It  is  almost  exactly  forty  years  since  these  drugs  were  first  used  in  this  country 
by  Dr.  T.  J.  Maclagan,  and  in  the  early  eighties  careful  statistics  were  made  to 
elucidate  the  value  of  such  treatment  as  compared  with  the  alkaline  method,  or 
the  natural  course  of  the  disease.  These  investigators  showed  conclusively 
that  pain  was  rapidly  relieved  and  fever  lowered.  Dr.  Pye  Smith  found  that  in 
1 80  out  of  355  patients  these  symptoms  were  arrested  in  five  days,  but  in  only 
3  out  of  24  cases  treated  expectantly  was  there  the  same  good  result. 

The  influence  upon  relapses  was  much  disputed  ;  Dr.  Pye  Smith  had  93 
relapses  in  his  355  cases;  Dr.  Donald  Hood  found  34  relapses  in  850  cases  treated 
without  these  drugs  (4  per  cent),  and  182  in  1250  cases  treated  -with  them 
(14-6  per  cent). 

To  the  writer,  it  seems  that  our  conception  of  rheumatism  has  so  changed  that 
it  is  not  possible  at  the  present  time  to  express  in  statistics  the  influence  of  the 
salicylates.  This  is  clear,  that  these  drugs  have  no  lasting  effect  upon  rheumatic 
processes,  for  fresh  infections  or  recrudescences  are  very  frequent  in  childhood ; 
but  acute  articular  rheumatism  is  greatly  relieved  and  the  pain  and  distress  are 
much  diminished.     For  these  reasons  the  prognosis  is  improved. 

There  are,  however,  some  cases  in  which  the  articular  symptoms,  though  less 
violent,  are  more  intractable,  requiring  large  doses  of  the  salicylates  to  keep  the 
symptoms  under  control.  It  is  a  matter  of  opinion  as  to  whether  there  are 
cases  in  which  these  drugs  are  ineffectual,  but  it  has  been  the  writer's  experience 
to  see  some  in  which,  while  several  of  the  joints  recover  completely,  others  drift 
into  a  rheumatoid  condition,  and  believing  as  he  does  that  there  is  a  rheumatic 
form  of  rheumatoid  arthritis,  he  is  not  prepared  to  accept  the  dictum  that  an 
arthritis  which  does  not  yield  to  the  salicylate  treatment  is  necessarily  non- 
rheumatic.  We  are  here  face  to  face  with  the  great  problem  of  the  present  time 
in  the  treatment  and  prognosis  of  rheumatic  fever — are  the  salicylates  specific 
antidotes  ?  This  much  we  can  assert  with  regard  to  the  arthritis,  that  when  it 
does  not  react  to  this  method  of  treatment,  and  yet  is  of  what  we  call  the  rheu- 
matic type,  the  prognosis  as  to  the  future  is  uncertain. 

Hyperpyrexia,  although  less  fatal  since  the  introduction  of  the  cold-bath 
treatment,  is  still,  in  spite  of  the  salicylates,  of  very  uncertain  prognosis.  In 
late  years  it  has  been  a  very  rare  occurrence;  the  diminution  in  frequency  did 
not  occur  at  the  time  of  the  introduction  of  salicylate  of  soda,  however,  but  some 
years  later,  and  this  may  mean  an  alteration  in  the  character  of  the  disease  of 


RHE  UMA  TIC     FE  VER  449 


temporary  duration,  rather  than  the  possession  of  any  real  control  of  Jthe 
symptoms. 

Mental  symptoms  may,  in  adult  life,  though  rarely,  add  considerably  to  the 
gravity  of  the  prognosis  of  acute  rheumatism.  Great  depression  and  even 
mental  derangement,  may  occur.  Unless  there  is  a  previous  history  of  mental 
instability,  a  gradual  recovery  may  be  expected.  Another  troublesome  group 
of  symptoms  in  the  adult  are  abdominal.  These  may  take  the  form  of  dilatation 
of  the  stomach  or  troublesome  vomiting  and  gastralgia,  or  again  of  pain  located 
apparently  in  the  large  bowel  and  leading  to  troublesome  distention  or  obstinate 
hiccough.  Recovery  may  be  much  delayed  by  these  complications.  Whether 
rheumatism  is  a  cause  of  acute  appendicitis  has  not  been  certainly  established, 
but  should  this  prove  to  be  the  case  it  is  clear  that  the  prognosis  in  such  a 
complication  is  to  be  judged  by  the  general  indications  that  govern  the  prognosis 
of  appendicitis.  Where  rheumatic  fever  attacks  a  patient  living  in  an  insanitary 
house,  the  character  may  become  almost  typhoidal.  There  is  great  prostration, 
and  the  tongue  becomes  dry  and  cracked,  the  course  is  long,  and  troublesome 
vomiting  may  prevent  the  use  of  the  salicylates.  Although  the  eventual  recovery 
may  be  good,  it  is  slow,  and  the  illness  may  last  for  months. 

There  is  little  to  guide  us  as  to  the  prognosis  of  future  attacks.  Our  common 
sense  tells  us  that  if  the  original  attack  in  an  adult  is  dependent  upon  some  gross 
exposure  to  chill  and  to  general  carelessness,  there  is  good  hope  that  with  proper 
care  in  the  future  the  first  attack  will  also  be  the  last. 

The  writer  believes  that  if  there  is  recurrent  tonsillitis  with  obviously  diseased 
tonsils,  their  enucleation  will  improve  the  outlook. 

In  general  terms,  then,  the  outlook  in  acute  articular  rheumatism  is  good 
as  to  life  and  to  complete  recovery  ;  but  such  a  general  statement  is  of  little 
value,  seeing  that  in  a  large  number  of  cases  the  heart  is  more  or  less  affected, 
and  that  upon  the  degree  of  this  affection  the  prognosis  in  acute  rheumatism 
mainly  depends.  In  children  the  articular  symptoms  are  of  little  prognostic 
importance. 

There  seems  no  serious  difference  in  the  prognosis  dependent  upon  the  variety 
of  salicylate  compounds  used  in  the  treatment.  Those  who  push  these  drugs 
usually  combine  the  sodium  salt  with  sodium  bicarbonate,  but  others  claim  that 
the  acid  aspirin  is  even  more  effectual.  In  the  severe  articular  forms  the 
writer  prefers  the  salicylate  of  sodium,  finding  it  less  likely  to  upset  the  digestion; 
but  it  must  be  premised  that  only  the  purest  drugs  are  used.  It  is  important 
to  remember  that  in  childhood,  if  these  drugs  are  pushed  too  heavily  and  without 
reference  to  the  particular  patient,  bad  and  even  fatal  results  may  follow  in  a 
case  of  moderate  severity. 

As  a  general  guide,  it  is  useful  to  recognize  three  classes  of  arthritic  lesions 
in  rheumatic  fever  : — 

1.  The  acute  severe  type,  recovering  rapidly  and  completely. 

2.  The  relapsing  subacute  type,  also  recovering,  but  more  slowly.  Such 
attacks  may  leave  some  weakness  in  the  larger  joints. 

3.  The  more  pernicious  type,  drifting  into  the  rheumatoid  group.  This  latter, 
many  authorities  regard  as  non-existent. 

There  may  be  great  muscular  wasting  in  some  of  these  cases  of  severe  rheumatic 
arthritis ;  and  in  children  in  whom  the  hands  are  badly  affected,  the  result 
may  resemble  precisely  the  rheumatoid  arthritis  of  young  adults.  Very  good 
recovery  m.ay,  however,  result,  though  the  improvement  is  generally  slow  and 
such  cases  are  not  frequent. 

The  prognosis  in  the  cardiac  affections  is  discussed  elsewhere  {see  Rheumatic 
Peri-,  Myo-,  a.nd  Endocarditis).  f.  J .  Poynlon. 

29 


450  INDEX     OF    PROGNOSIS 

RHEUMATIC  PERI-,  MYO-,  AND  ENDOCARDITIS  (ACUTE).— It  is  most 
essential  that  we  realize  that  these  three  lesions  are  not  as  a  rule  independent 
entities  in  rheumatisna,  but  that  the  cardinal  lesion  of  severe  types  is  a  carditis 
aiiecting  to  a  greater  or  lesser  extent  all  parts  of  the  heart.  Both  in  the  child 
and  adult  these  cardiac  lesions  are  the  ones  that  chiefly  influence  the  prognosis 
of  rheumatic  fever,  and  because  of  their  greater  frequency  in  the  child  it  is 
generally  admitted  that  the  prognosis  is  the  more  serious  at  this  early  age. 

The  outlook  is  very  grave  when  severe  carditis  occurs  in  a  child  with  a  family 
history  of  rheumatism  on  both  sides,  in  the  very  young  (five  years  and  under),  and 
in  those  who  are  surrounded  by  poverty  and  neglect. 

The  most  virulent  cases  are  liable  to  commence  abruptly  with  somewhat 
unusual  symptoms,  such  as  vomiting  and  diarrhoea,  severe  shivering  or  sudden 
acute  thoracic  pains,  and  considerable  fever.  On  the  other  hand,  we  must  be 
prepared  to  find  that  a  general  carditis  may  gradually  appear  in  some  delicate 
children  with  remarkably  few  alarming  signs,  and  though  the  course  is  more 
protracted  than  in  the  first  group,  the  ultimate  result  may  be  most  unfavourable. 

I.  Pericarditis. — This  is  the  commonest  cause  of  a  fatal  event  in  acute  rheu- 
matism. The  cause  of  death  is  the  general  carditis,  but  the  pericardial  lesion 
is  the  most  evident  warning  of  this  occurrence. 

Some  of  the  most  dangerous  cases  show  remarkably  little  fever,  and  in  the  last 
days  of  the  illness  the  chart  may  even  give  a  subnormal  record.  This  is  a  point 
that  should  not  be  lost  sight  of  b}^  those  who  regard  a  fall  of  temperature  at 
the  time  of  the  administration  of  salicylates  as  necessarily  a  good  omen.  Livid 
pallor,  a  rapid  small  pulse,  great  dilatation,  and  feeble  cardiac  sounds  are  signs 
of  a  deadly  infection,  whether  nodules  develop  or  not.  Delirium  is  a  bad  sign, 
but  it  is  not  at  all  frequent  in  childhood.  The  fatal  issue  may  be  unexpectedly 
abrupt  from  syncope.  Those  who  are  acquainted  with  this  virulent  form  of 
rheumatism  will  recognize  at  once  from  the  general  appearance  and  rapid 
development  of  the  heart  disease  that  the  prognosis  is  very  bad,  for  should 
the  patient  rally  for  the  time,  the  heart  is  usually  irretrievably  damaged,  and 
the  more  speedy  death  is  really  the  happier  event.  Fortunately,  these  cases 
are  comparatively  rare,  and  we  know  that  pericarditis  is  more  often  an  event 
in  a  recurrent  attack  of  cardiac  rheumatism.  This  fact  is  one  of  considerable 
interest,  for  it  reminds  us  that  with  recurrent  infection  the  resistance  seems  to 
lessen,  a  principle  which  may  be  also  applied  to  the  endocardial  lesions. 

The  occurrence  of  nodules  is  much  more  frequent  in  the  child  than  in  the 
adult,  and  the  lesion  is  one  which  leads  us  to  consider  with  particular  care  the 
prognosis  of  the  case.  Dr.  Cheadle  made  the  general  statement  that  these 
lesions  were  as  a  rule  associated  with  grave  heart  disease,  and  that  the  prognosis 
was  accordingly  grave.  This  general  rule  holds  good.  Thus,  of  39  of  the  writer's 
cases  that  came  to  hospital  showing  nodules  among  other  manifestations, 
15  died. 

Although,  then,  this  lesion  is  a  very  important  one  in  prognosis,  we  must  not 
fall  into  the  error  of  looking  upon  its  occurrence  as  a  sentence  of  death.  The 
writer  has  seen  rare  cases  in  which  the  heart  has  been  scarcely  damaged,  and 
in  which  excellent  recovery  has  followed.  There  are  other  cases  in  which  the 
nodules  disappear,  and  the  heart,  though  damaged,  makes  a  good  recovery  and 
becomes  well  compensated,  and  the  child  does  not  suffer  from  another  attack 
of  rheumatism  while  under  observation.  We  must  guard  against  the  error  of 
mechanical  precision  in  judging  of  these  cases,  and  not  permit  ourselves,  on 
detecting  nodules,  to  state  dogmatically  that  the  condition  is  hopeless  ;  on  the 
contrary,  though  justified  in  fully  admitting  their  prognostic  importance,  we 
must  judge  each  case  by  the  broad  lines  of  clinical  inquiry,  and  above  all  must 


RHEUjMATIC    peri-,    MYO-:   AND    ENDOCARDITIS  451 

estimate  the  degree  of  cardiac  damage.  This  is  the  more  necessary  because  it 
may  not  have  occurred  to  some  physicians  that  these  nodules  are  only  the  visible 
evidence  of  a  process  which  occurs  elsewhere  in  the  subcutaneous  tissues  without 
forming  visible  projections,  as  post-mortem  and  histological  investigation  has 
shown.  This  being  the  case,  it  is  quite  possible,  though  clearly  difficult  of  proof, 
that  in  many  more  cases  than  we  think,  some  degree  of  local  subcutaneous  infection 
occurs  short  of  obvious  nodule  formation,  and  the  actual  appearance  of  the 
prominences  will  then  only  represent  a  somewhat  greater  severity  of  this  same 
process. 

In  adolescents  the  occurrence  of  nodules  is  also  as  a  rule  associated  with 
grave,  but  by  no  means  necessarily  fatal,  heart  disease. 

Among  the  less  virulent  cases,  we  can  recognize  a  group  in  childhood  in  which 
there  is  obstinate  and  recurrent  carditis,  with  a  subacute  and  recurrent  peri- 
carditis. In  these  there  are  numerous  manifestations,  such  as  nodules  and 
erythemata,  endocarditis  is  invariable,  and  more  than  one  valve  may  be  attacked. 
The  outlook  is  bad,  for  though  these  children  may  pass  through  one  or  more 
attacks,  even  in  convalescence  they  never  seem  to  be  quite  free  from  rheumatism, 
and  the  heart  is  irretrievably  damaged.  In  London  we  see  a  number  of  these 
cases,  of  all  degrees  of  severity,  and  they  include  some  of  our  most  favourite  and 
our  most  familiar  hospital  in-patients.  There  is  a  third  group  in  which  only  a 
single  acute  attack  of  pericarditis  may  occur,  and  among  them  occur  examples 
of  remarkable  recovery,  the  heart  apparently  throwing  off  the  infection  with 
very  little,  if  any,  permanent  injury.  In  a  few  of  these  the  cardiac  valves  seem 
to  escape  entirely,  although  such  an  event  always  rouses  the  suspicion  that  the 
illness  is  not  rheumatic.  These  are  not  difficult  cases  to  recognize  ;  the  child  is 
usually  a  strong  one,  the  pericarditis  is  evanescent,  the  symptoms  are  mild, 
and  the  cardiac  dilatation  is  fleeting.  Unfortunately,  in  the  hospital  class  we 
do  not  meet  with  many  of  them,  but  in  the  well-to-do  they  are  more  frequent. 

In  the  adult,  pericarditis  is  much  less  frequent,  but  when  it  occurs  the  prognosis 
must  always  be  cautious,  for  here  again  it  is  an  indication  of  a  grave  infection, 
and  the  damage  to  the  myocardium  is  at  this  age  a  very  serious  event.  Never- 
theless, there  are  all  grades  of  severity  in  the  adult  as  in  the  child,  and  good 
recovery  may  occur  even  when  the  patient  is  over  fifty  years  of  age.  The  guiding 
principles  lie  in  the  estimation  of  the  virulence  of  the  attack  and  the  degree  of 
cardiac  failure  that  results. 

The  prognosis  of  carditis  and  pericarditis  must  also  be  influenced  by  the 
degree  of  care  in  convalescence.  At  all  ages  this  is  of  the  greatest  importance, 
and  it  is  very  advisable  to  picture  the  pathological  changes  that  occur  in  this 
carditis,  for  thus  alone  can  we  realize  the  time  that  is  needed  for  the  inflammation 
to  subside,  the  exudation  to  be  absorbed  or  organized,  and  the  heart  to  compen- 
sate for  the  necessary  impairment  of  functions.  Attention  must  be  paid  not 
only  to  the  physical  signs  in  the  heart,  but  also  to  the  general  condition  of  the 
patient,  for  the  heart  may  show  good  evidence  of  recovery,  but  the  delicacy  of 
the  patient  may  warn  us  not  to  commence  to  apply  the  test  of  increasing  calls 
upon  its  powers  until  this  recovery  has  become  assured  for  some  while.  We 
have  to  be  continually  reminding  the  parents  that,  for  the  child,  the  problem  is 
not  one  of  the  immediate  future  but  of  his  whole  career. 

It  is  useful  in  considering  the  prognosis  of  rheumatic  pericarditis  to  recognize 
three  main  types  : — 

1.  The  acute  and  transient. 

2.  The  subacute  and  relapsing. 

3.  The  virulent  form  proving  rapidly  fatal,  or,  if  less  severe,  leading  irresistibly 
into  the  second  variet3^ 


452  INDEX     OF     PROGNOSIS 

The  influence  of  adherent  pericardium  upon  the  prognosis  takes  us  beyond  the 
scope  of  acute  rheumatism.      [See  Pericarditis.) 

Pericarditis  is  always  a  long  illness,  although  in  the  most  favourable  cases  all 
activity  of  the  lesion  may  be  over  in  three  weeks.  The  quieting  down  of  active 
symptoms  marks,  however,  only  the  commencement  of  that  very  gradual  and 
cautious  convalescence  upon  which  the  real  progress  so  greatly  depends.  The 
guiding  principle  in  this  stage  is  not  to  take  an  abstract  period  of  time,  but  to 
study  the  behaviour  of  the  heart  in  each  cautious  forward  step.  Some  patients 
get  forward  much  faster  than  others,  and  these  lose  rather  than  gain  by  prolonged 
and  complete  rest.  Others  need  more  rest  than  would  have  been  expected.  In 
both  instances,  if  progress  is  cautious,  we  can  alter  the  details  without  doing  any 
real  harm,  even  if  the  advance  has  been  a  little  too  rapid.  It  is  the  abrupt  transi- 
tion from  invalidism  to  ordinary  life  that  may  alter  the  prognosis  of  this  condition 
from  good  to  bad.  The  temperature,  the  pulse-rate,  the  character  and  position 
of  the  cardiac  impulse,  and  the  nutrition  of  the  patient  are  guiding  points.  Three 
weeks  of  normal  temperature  after  a  rheumatic  pericarditis  is,  in  general  terms,  a 
useful  time  to  allow  before  attempting  to  make  any  forward  step  at  all. 

2.  Acute  Myocarditis. — The  importance  of  this  is  well  recognized,  but  the 
accurate  estimation  of  its  severity  is  not  yet  within  our  powers,  and  for  this 
reason  we  must  temper  dogmatism  with  caution.  The  more  modern  methods 
of  cardiac  examination  are  helping  us  with  the  study  of  arrhythmias  that  may 
result  from  rheumatic  myocarditis,  but  we  must  not  take  the  occurrence  of 
arrhythmia  as  necessarily  an  index  of  the  power  or  weakness  of  the  cardiac 
muscle,  and  we  must  remember  also  that  the  unit  of  arrhythmia — the  extra- 
systole  or  premature  contraction — is  one  which  requires  much  more  study 
before  its  true  meaning  is  understood.  Acute  dilatation  from  myocardial 
poisoning  may  prove  fatal  even  in  childhood,  but  it  is  a  very  rare  occurrence. 
When  it  occurs,  there  are  such  clear  signs  of  cardiac  failure  and  intense  illness 
that  the  danger  is  apparent. 

A  much  more  frequent  occurrence  is  cardiac  dilatation,  followed  by  the  failure 
of  the  heart  to  compensate  for  a  mitral  lesion  which  clinically  appears  to  be  one 
of  ordinary  severity.  These  are  the  mitral  cases  that  run  such  a  disastrous 
course  at  all  ages.  The  action  of  the  heart  remains  feeble  and  rapid,  and  the 
dilatation  only  recovers  in  part.  The  child  is  short  of  breath,  and  cardiac  tonics 
do  not  produce  the  effect  that  is  wished.  An  adult,  if  forced  by  circumstances 
to  return  to  work,  soon  breaks  down,  with  evident  signs  of  mitral  insufficiency. 
In  such  cases,  the  factor  of  an  adherent  pericardium  always  comes  in  for  considera- 
tion, but  there  is  no  doubt  that  in  many  of  them  no  such  complication  has 
occurred.  There  can  be  little  doubt  that  the  most  important  element  in  the 
prognosis  is  the  early  recognition  of  this  myocardial  weakness,  and  a  determined 
attempt  to  cope  with  it  by  prolonged  rest  and  care  at  its  first  appearance.  When 
once  such  a  heart  as  this  has  been  overstrained,  the  outlook  is  bad.  It  need 
hardly  be  added  that,  if  this  be  true  of  mitral  cases,  it  is  even  more  so  of  aortic 
or  combined  mitral  and  aortic  lesions. 

There  is  a  third  group  of  cases  in  which  the  myocardium  appears  to  suffer 
almost  alone,  and  the  valves  to  escape  ;  these  are  not  the  virulent  acute  cases 
mentioned  above,  but  those  in  which,  after  an  attack  of  rheumatism,  the  heart 
remains  dilated,  the  action  rapid  and  often  irregular,  pallor,  and  symptoms  of 
breathlessness,  nervousness,  and  palpitation,  with  or  without  syncopal  attacks, 
are  prominent,  and  there  is  a  real  danger,  owing  to  the  absence  of  a  definite 
valvular  murmur,  of  considering  the  condition  as  neurasthenic.  Such  a  condition 
is  very  obstinate,  but  in  childhood  good  recovery  may  be  made  after  many 
months.     In  adult  life  much  will  depend  upon  the  occupation.     The  mildest 


RHEUMATIC    PERI-,    MYO-,    AND    ENDOCARDITIS  453 

examples  of  this  condition  are  the  transient  dilatations  which  occur  so  frequently 
in  first  attacks  of  rheumatic  heart  disease,  and  from  which  recovery  may  be 
rapid  and  complete,  if  their  true  meaning  is  appreciated. 

It  will  be  apparent  that  in  dealing  with  the  prognosis  of  myocarditis  in  rheuma- 
tism we  are  continually  driven  to  realize  its  existence,  not  by  a  clinical  sign,  but 
by  evidence  that  we  have  put  too  great  a  strain  upon  a  heart  which  we  believed 
was  stronger  than  proved  to  be  the  case.  This  difficulty  must  always  be  remem- 
bered as  one  of  the  most  important  facts  in  the  study  of  rheumatic  heart  disease. 

Once  more  we  may  usefully  recognize  three  classes  : — 

1 .  The  acute  simple  dilatation  which  with  care  recovers  completely. 

2.  The  subacute  obstinate  cases  that  require  much  time  and  caution  before  a 
good  result  is  obtained. 

3.  The  virulent  cases  which  may  actually  prove  fatal,  but  more  frequently 
much  increase  the  danger  of  concomitant  pericardial  and  endocardial  lesions. 

3.  Acute  Endocarditis. — Simple  rheumatic  endocarditis  is  never  fatal,  for  the 
lesions  are  small,  and  would  be  negUgible  if  it  were  not  for  the  functions  of  the 
structure  attacked  ;  but  the  bearing  of  these  lesions  upon  the  ultimate  prognosis 
is  of  immense  importance. 

We  can  lay  down  some  useful  guiding  lines  upon  this  point  from  clinical  experi- 
ence. We  recognize  that  the  combined  aortic  and  mitral  lesion,  particularly  if 
the  aortic  is  predominant,  is  a  grave  event.  In  childhood  these  cases,  if  severe, 
usually  point  to  a  great  tendency  to  develop  future  attacks,  and  to  a  fatal  termin- 
ation before  adult  life  is  reached.  The  writer  believes  that  if  they  survive  to 
early  adult  life  they  are  prone  to  develop  malignant  rheumatic  endocarditis, 
and  sometimes  they  develop  frequent  attacks  of  angina  pectoris.  The  solitary 
aortic  lesion  is  rare  in  childhood,  but  if  severe  the  prognosis  is  bad. 

Simple  mitral  endocarditis,  if  associated  with  grave  myocardial  weakness, 
runs  a  very  disastrous  course  in  the  young  ;  but  when,  as  is  more  usual,  it  is 
compensated,  the  outlook  is  good.  If  there  is  no  further  rheumatism,  many  of 
these  cases  recover  in  a  way  which  can  hardly  be  realized  until  they  have  been 
followed  for  some  five  or  six  years.  The  murmur,  which  was  loud,  and  heard 
over  a  wide  area,  may  disappear,  or  only  be  audible  when  the  child  is  lying  down, 
and  even  then  perhaps  only  be  recognized  b}^  the  physician  who  has  followed  the 
case  closely. 

The  writer  believes  that  slight  aortic  lesions  may  also  sometimes  disappear. 

Mitral  stenosis  does  not,  as  a  rule,  give  rise  to  symptoms  in  childhood,  although 
its  origin  is  frequent  at  this  age,  but  if  it  does  the  outlook  is  bad.  If  before 
puberty,  recurrent  bronchitis,  embolism,  or  attacks  of  tachycardia,  and  cyano.sis 
with  dyspnoea,  have  occurred,  or  if  there  has  been  an  attack  of  heart  failure 
with  dropsy  as  the  result  of  this  lesion,  we  must  be  prepared  for  invalidism  and 
early  death.  On  the  other  hand,  slight  mitral  stenosis,  though  always  more 
serious  than  slight  regurgitation,  may,  after  childhood,  never  make  headway,  and 
a  useful  life  may  follow.  When,  however,  we  take  a  broad  survey  of  this  lesion 
and  couple  with  it  the  greater  frequency  of  rheumatism  in  the  poorer  classes,  we 
are  forced  to  the  conclusion  that  it  represents  a  form  of  rheumatism  which  is 
very  prone  to  dog  the  footsteps  of  its  victim  through  life,  and  we  find  that  death 
is  very  usual  under  forty-five  years  from  chronic  heart  disease,  or  some  accident 
associated  with  the  lesion. 

The  following  statistical  points  may  be  of  service  in  helping  the  reader  to 
focus  some  of  the  facts  that  bear  upon  the  prognosis  of  rheumatic  heart  disease. 

Taking  150  fatal  cases  in  children  under  twelve  years  of  age,  we  find  the 
mortality  somewhat  greater  in  females  :  59  per  cent,  as  against  41  per  cent  in 
males. 


Up  to 

3I  years 

3i  to 

4i        .. 

4i  to 

5i        „ 

5i  to 

64        „ 

6|  to 

74      .. 

74  to 

84        „ 

8^  to 

94      .. 

9i  to 

loi- 

loi  to 

114 

454  INDEX     OF     PROGNOSIS 

Allowing  for  the  great  difficult}^  there  is  in  establishing  without  doubt  that 
any  particular  attack  is  a  first  one,  about  30  per  cent  of  fatal  cases  occur  in  the 
first  attack. 

The  age  incidence  of  fatal  cases  rises  to  about  the  tenth  3'ear,  thus  : — 

0-6  per  cent. 

-  3-9 
7-4 
9-4 

-  12-7 

-  12-7 

-  15-3 
20  ,, 
12 

At  least  86  per  cent  of  fatal  cases  of  rheumatic  heart  disease  show  active 
rheumatism  in  the  last  illness,  and  death  from  chronic  heart  disease  alone  is  very 
unusual.  The  cardiac  lesions  found  after  death  are  very  definite  and  often  very 
extensive. 

In  at  least  90  per  cent  the  pericardium  is  more  or  less  damaged. 

The  mitral  valve  was  damaged  in  149  out  of  150  cases,  the  aortic  valve  in 
34  per  cent,  the  tricuspid  in  24  per  cent,  and  the  pulmonary  in  3  per  cent. 

The  multiple  valvular  lesions  in  the  severe  rheumatism  of  childhood  are  well 
exemplified  by  these  numbers. 

When  confronted  with  a  case  of  acute  rheumatism  in  a  child  of  five  years  or 
under,  the  following  figures  will  give  an  idea  of  the  conditions  that  may  be 
expected. 

Eight  out  of  52  such  cases  proved  fatal,  that  is,  about  16  per  cent. 

Definite  heart  disease  occurred  in  about        -     85  per  cent. 
Arthritis  or  arthritic  pains     -  -  -  -70 

Chorea  -------35.. 

Sore  throat    -         -         -         -         -         -         -     20 

Nodules  -         -         -         -         -         -         -15 

When  we  turn  to  adolescents  and  adults,  and  look  into  the  after-histories  of  a 
considerable  number,  we  come  upon  a  very  suggestive  and  interesting  fact. 
Putting  aside  as  beyond  the  scope  of  this  article  the  numerous  cases  of  death 
from  chronic  heart  disease,  we  find  the  great  danger  is  not  carditis,  but  malignant 
endocarditis. 

This  point  has  such  close  bearing  upon  the  prognosis  in  acute  rheumatism, 
that  the  writer  feels  that  he  is  not  trespassing  upon  the  ground  of  another  contri- 
butor when  he  gives  the  examples  shown  in  the  table  on  the  opposite  page. 

Closely  allied,  and  probably  of  the  same  nature,  were  7  further  cases  in  adults, 
the  victims  of  repeated  rheumatism  in  childhood,  who  showed  many  of  the  signs 
of  malignant  endocarditis,  and  eventually  recovered  for  the  time,  after  long  and 
dangerous  illnesses. 

It  is  evident,  then,  that  the  physician  who  deals  with  acute  rheumatism  in  the 
adolescent  and  adult  must  take  into  account  the  possibility  of  malignant  endo- 
carditis, and  this  particularly  in  the  cases  in  which  the  aortic  and  mitral  valves 
have  been  both  damaged  by  previous  rheumatism.  Whatever  interpretation  he 
may  choose  to  put  upon  the  occurrence  of  these  malignant  lesions,  the  fact  of 
their  intimate,  and  in  the  writer's  opinion  direct,  association  with  the  nature  of 
the  early  illnesses  cannot  be  put  aside  in  the  prognosis  of  acute  rheumatism. 


RHEUMATOID     ARTHRITIS 


455 


A  study  of  2O0O  post-mortem  examinations  upon  adults  brought  home  this  fact 
to  the  writer,  that  more  rheumatic  patients  die  from  malignant  endocarditis  than 
from  an  acute  rheumatic  carditis  such  as  occurs  in  children,  or  indeed  from  any 
form  of  acute  rheumatism  that  is  generally  recognized. 

Table  Showing  the  Sequence  of  Malignant  Endocarditis 
UPON  Attacks  of  Acute  Rheumatism. 


Onset  of 

Sex 

Onset  of  Acute  Rheumatism 

Malignant 
Endocarditis 

M 

10  years      ----- 

13  years 

M 

6,  8,  and  10  years      - 

10  ',, 

F 

23  years 

37     „ 

F 

12  and  13  years 

14     „ 

F 

7  and  20  years  -         -         -         - 

21     „ 

F 

As  a  child           -         .         .         . 

37     „ 

M 

11,  14,  17,   and  18  years     - 

19     „ 

M 

42  years       ----- 

50     „ 

F 

12  years      ----- 

16     „ 

M 

As  a  boy  and  at  16  years     - 

27     „ 

F 

12  years      ----- 

16     „ 

M 

7  years        _         -         -         -         - 

13     ., 

F 

12  years      ----- 

17     „ 

F 

8,  13,  and  15  years     - 

24     „ 

F 

38  years      .         -         -         .         . 

48     „ 

M 

18  3'ears      .         -         .         -         - 

28     ,. 

F 

13  and  17  years 

27     „ 

F 

As  a  child 

32     „ 

The  influence  of  treatment  by  special  drugs  or  by  special  methods  upon  the 
prognosis  of  rheumatic  endocarditis  is  most  difficult  to  estimate.  The  most 
important  claim  in  recent  years  has  been  that  the  salicyl  group,  if  used  effectively, 
is  a  specific  to  the  rheumatic  process.  The  writer  is  not  himself  at  all  convinced 
upon  this  point,  and  would  express  his  own  view  by  the  statement  that  in  a  case 
of  severe  rheumatic  carditis  he  would  not  feel  confident  that  pushing  these  drugs 
would  not  do  harm  rather  than  good.  He  has  seen  this  method  of  treatment 
used  on  many  occasions,  and  yet  at  the  time  of  writing  has  still  this  feeling  of 
lack  of  conviction.  There  seem  to  him  no  convincing  papers,  and  the  recent  one 
by  Dr.  R.  Miller  in  the  Quarterly  Journal  of  Medicine  appears  to  him  to  be  more 
of  the  nature  of  a  defence  of  the  administration  of  large  doses  than  a  proof  of 
their  value.  Doubtless,  the  truth  will  be  ascertained  in  the  future.  Such  a 
method  as  Dr.  Caton's  has  much  improved  the  prognosis  of  early  endocarditis 
by  demanding  a  complete  rest  for  the  patient,  while  a  definite  procedure,  which 
in  itself  would  appear  to  be  devoid  of  any  danger,  is  being  carefully  carried  out 
by  the  physician.  f,  j,  Poynton. 

RHEUMATOID  ARTHRITIS. — The  prognosis  of  rheumatoid  arthritis  must 
be  made  at  present  on  broad  and  general  lines,  for  we  have  to  realize  that  a 
considerable  change  in  the  attitude  toward  the  nature  of  the  condition  has  taken 
place  in  recent  years.  There  is  a  general  feeling  that  some  infective  process  is 
the  exciting  cause  of  the  condition,  or,  what  is  probably  more  correct,  that  a 
variety  of  infective  processes  are  concerned.  The  tendency  now  is  to  lay  much 
emphasis  upon  the  infection,  and,  from  the  point  of  view  of  investigation,  this 
attitude  seems  to  offer  the  best  chance  of  making  advance.  Nevertheless,  when 
we  come  to  consider  prognosis,  we  must  admit  that  in  many  cases  no  causal 


456  INDEX     OF     PROGNOSIS 

infection  has  been  demonstrated,  and  must  further  bear  in  mind  that  the  indi- 
vidual constitution — whatever  the  nature  of  rheumatoid  arthritis  may  be — has 
probably  an  important  bearing  upon  the  course  of  the  illness.  It  would  be,  then, 
a  mistake  to  lose  sight  of  possible  fallacies  in  the  present  state  of  our  knowledge. 
Thus,  for  example,  a  patient  may  be  suffering  from  some  degree  of  pyorrhoea 
alveolaris,  but  it  does  not  necessarily  follow  that  this  is  the  determining  cause  of 
an  associated  rheumatoid  arthritis.  The  writer's  experience  must  be  that  of 
many  others  in  finding  that  a  patient  has  had  clear  evidence  of  rheumatoid 
arthritis  at  a  time  when  the  teeth  and  gums  were  in  excellent  order,  and  j'et 
some  years  later,  with  failure  of  health,  both  teeth  and  gums  have  become 
diseased,  and  the  rheumatoid  arthritis  is  still  in  evidence. 

In  other  cases,  unhealthy  conditions  have  been  corrected,  but  no  obvious 
change  in  the  course  of  the  disease  has  followed.  He  would  be  the  first  to  aUow 
that  the  primary  step  in  the  study  of  such  a  case  is  a  search  for  some  local  focus 
of  infection,  but  is  not  prepared  yet  to  admit  that  its  discovery  has  necessarily 
solved  the  problem  of  the  origin  of  the  disease.  Although  encouraged  by  such  a 
discovery  to  hope  that  a  means  of  diminishing  the  severity,  or  even  of  arresting 
the  course,  of  the  disease  had  been  found,  he  could  not  confidently  assure  his 
patient,  on  the  evidence  at  present  available,  that  such  a  happy  event  would  follow. 

Then,  again,  we  must  admit  that  in  a  considerable  number  of  cases  we  can  find 
no  focus.  This  is  certainly  no  proof  that  the  condition  is  not  infective,  for,  when 
all  is  said,  the  demonstration  of  an  obvious  local  focus,  though  of  the  greatest 
importance,  is  an  example  of  a  somewhat  crude  method  of  infection.  We  do  not 
always  find  gross  local  foci  in  cases  of  tuberculosis,  or  of  pneumococcal  infection, 
or  of  the  rheumatic,  for  these  infections  may  gain  access  to  the  system  without  a 
great  parade  at  their  site  of  entrance. 

Dr.  James  Lindsay's  statistics  upon  this  question  of  infective  foci  are  of 
interest. 

In  138  cases  in  females  : — 

No  focus  was  found  in  -  "65 

Vaginal  discharge  in     -  -  -  36 

Pyorrhoea  alveolaris  in  -  -  19 

Otorrhoea       -----  7 

Gastric  ulceration           -  -  -  5 

After  childbirth    -          -  -  -  4 

Rhinorrhoea            -          -  -  -  i               * 

Chronic  tonsillitis           -  -  -  i 

Thus,  in  almost  50  per  cent  of  these  cases,  no  infective  focus  was  forthcoming. 

The  prognosis  then  must  clearly  be  based  on  broad  lines,  to  some  of  which 
consideration  will  now  be  given. 

Predisposing  Causes. — i.  The  family  history  is  doubtless  of  some  importance, 
for  we  cannot  but  believe  that  the  occurrence  of  the  disease  in  several  generations 
and  members  of  the  same  famil}^  points  to  a  weakened  resistance  to  the  infection, 
if  there  be  one,  or  to  some  mysterious  metabolic  perversion  if  the  fault  should  lie 
there. 

2.  The  question  of  age  incidence  introduces  the  usual  difficulty  of  deciding 
what  is  to  be  called  rheumatoid  arthritis,  and  upon  which  there  is  no  agreement 
at  present  possible  ;  but  we  find  that  the  disease  in  early  life  is  likely  to  be  more 
virulent,  whereas  in  more  advanced  life,  the  natural  tendency''  to  degenerative 
lesions  in  the  joints  favours  chronicity  and  crippling. 

3.  Sex. — The  liability  to  rheumatoid  arthritis  in  females  is  undoubtedly 
greater  than  in  males  ;    but  when  it  occurs  in  the  male  it  may  be  equally  severe. 


RHEUMATOID    ARTHRITIS  457 


4.  The  mode  of  onset  is  of  some  importance.  There  is  a  group  of  cases  in  which 
rheumatoid  arthritis  begins  acutely  and  affects  many  joints,  producing  rapid 
destruction.  Among  these  cases,  often  called  acute  rheumatoid  arthritis,  are 
some  of  the  worst  examples  of  the  disease.  These  are  easily  recognized  by  the 
fever,  general  toxsemia,  and  extensive  and  severe  lesions.  On  the  other  hand, 
when  they  are  less  severe,  although  there  may  be  much  damage,  the  eventual 
recovery  may  be  fair,  and  no  second  attack  need  necessarily  occur.  In  any  case, 
the  illness  will  certainly  be  long  and  recovery  slow. 

5.  Another  very  important  group  begins  with  acute  symptoms  affecting  a  few 
joints,  or  possibly  only  one.  The  onset  is  to  this  extent  acute,  but  the  general 
illness  slight.  In  this  group  the  cause  is  often  obscure  and  the  tendency  to 
further  attacks  very  decided.  The  most  experienced  may  make  grievous  mis- 
takes in  prognosis  here,  because  there  is  at  present  nothing  certain  to  guide  the 
opinion.  The  first  attack  was  mysterious,  and  the  cause  equally  so.  Accord- 
ingly, we  find  such  patients  coming  to  us  a  year  or  two  later  much  crippled,  and 
complaining  that  they  were  told  at  the  time  of  their  first  attack  that  if  they  did 
so  and  so,  and  underwent  such  and  such  a  course  of  treatment,  they  would  be 
cured  in  six  months.  The  essential  point  to  remember  is  that  when  an  arthritis 
of  mysterious  origin  occurs  and  shows  a  tendency  to  be  recurrent,  the  prognosis 
must  always  be  tinged  with  caution.  In  another  group,  the  onset  is  even  more 
gradual,  with  mysterious  pains  and  vasomotor  changes,  and  these  may  prove  to 
be  most  intractable,  and  end  in  complete  disablement.  Once  again,  the  unknown 
factors  in  the  disease  baffle  accurate  prognosis. 

6.  Occupation. — It  is  probable  that  occupation  is  of  very  considerable  import- 
ance in  prognosis.  The  writer  has  been  struck  by  the  great  severity  of  the  disease 
in  school  teachers.  The  nerve-wearing  life  of  the  board  schools,  the  effort  to  be 
of  rather  more  importance  than  one  can  afford  to  be,  and  the  struggle  to  get  the 
necessary  qualifications  to  reach  this  position,  seem  to  combine  in  undermining 
the  resistance  to  this  disease  in  the  most  deadly  fashion. 

Again,  there  can  be  no  doubt  that  long  and  anxious  nursing  of  a  near  relative, 
or  any  other  continual  nerve-strain,  may  antedate  a  most  serious  rheumatoid 
arthritis,  or  greatly  aggravate  the  course  of  the  disease  if  it  has  already  com- 
raenced. 

7.  Surroundings  are  also  important.  There  seems  no  doubt  that  cold  damp 
houses,  a  low-lying  swampy  country,  and  a  heavy  clay  soil,  foster  the  chronicity 
of  this  disease.  A  favourite  garden  may  do  much  harin  to  a  delicate  patient  who 
is  threatened  with  rheumatoid  arthritis.  Damp,  changeable  climates,  such  as 
our  own,  are  generally  agreed  upon  as  favouring  the  disease. 

It  is  clear,  therefore,  that  in  making  a  prognosis  we  must  take  a  broad  survey 
of  the  general  position,  as  well  as  pay  close  attention  to  the  special  points  in  the 
particular  case.  Bearing  in  mind,  then,  these  general  indications,  we  come  next 
to  the  prognosis  in  the  particular  case,  and  find  that  this  is  a  complicated  problem. 
The  danger  to  life  in  general  terms,  and  with  rare  exceptions,  is  indirect  rather 
than  direct  ;  the  joy  of  living  is  destroyed  far  more  often  than  life  itself.  There 
are,  nevertheless,  two  important  points  in  the  prognosis  :  one  concerned  with  the 
general  constitutional  disturbance,  the  other  with  the  local  arthritic  lesions. 

Cases  in  which  profound  toxaemia  is  evident  in  the  sallow  pallor,  general  depres- 
sion, bouts  of  fever,  loss  of  strength,  tachycardia,  and  vasomotor  changes,  are 
among  the  most  serious.  In  such,  multiple  arthritic  lesions,  sometimes  of  great 
extent,  are  coupled  with  profound  muscular  wasting.  In  such,  too,  grave  signs 
of  organic  lesions  of  the  spinal  cord  occasionally  develop.  In  every  direction 
treatment  is  embarrassed  by  the  loss  of  strength  and  hope,  by  the  distress  on 


458  INDEX     OF     PROGNOSIS 

movement,  and  by  the  spontaneous  neuritic  pains.  Among  them  are  some  of 
the  most  terrible  examples  of  human  suffering  that  are  known  in  the  field  of 
medicine. 

On  the  other  hand,  if  the  cachexia  yields  to  treatment,  and  the  arthritic  lesions 
are  not  too  far  advanced,  we  know  that  in  young  subjects  after  a  prolonged  illness 
sometimes  remarkable  recovery  may  occur.  Joints  which  only  show  active  peri- 
articular lesions  are  not  beyond  hope,  but  it  is  when  the  atrophic  shrivelling  of 
the  tissues  supervenes  that  we  realize  that  recovery  of  the  affected  parts  is  not 
possible. 

The  less  virulent  but  mysteriously  relapsing  cases  are  of  most  uncertain  prog- 
nosis, and  number  among  them  many  courageous  but  hopelessly  crippled  patients, 
who  live  for  years  fighting  against  increasing  disability.  Yet  we  see  in  this  group 
many  cases  in  which  the  relapses  cease  as  mysteriously  as  they  appeared,  and 
then  there  may  be  fair  recovery,  with  a  greater  or  less  degree  of  infirmity,  when 
hope  has  been  almost  abandoned. 

When  the  condition  occurs  in  the  elderly,  there  is  much  more  likelihood  of 
degenerative  lesions  occurring  ;  the  synovial  membranes  become  greatly  hyper- 
trophied,  loose  bodies  embarrass  the  joint  and  cartilage,  and  bone  may  be  greatly 
damaged.  In  these  cases  only  a  few  joints — but  unfortunately  often  the  knees  — 
may  be  involved.  Such  patients  may  be  stout  and  heavy,  and  their  muscles 
weak ;  accordingly,  though  the  disease  may  be  very  limited,  the  crippling  is 
great. 

The  factor  of  injury  has  also  to  be  reckoned  with,  for  these  insecure  joints  are 
very  likely  to  be  wrenched  by  a  sudden  false  movement,  and  injury  produces  a 
very  serious  change  for  the  worse  in  such  diseased  tissues. 

Injury,  indeed,  is  sometimes  credited  with  being  the  determining  factor  ;  but 
though  it  may  be  the  means  of  drawing  attention  to  the  condition,  the  writer 
believes  that  if,  as  is  often  the  case,  other  articulations  become  involved,  the 
injury  is  only  a  secondary  factor,  and  he  would  judge  of  the  prognosis  in  such 
cases  as  in  those  of  the  same  type  without  any  traumatic  history.  The  condition 
of  the  digestion  and  the  bowels  influences  prognosis.  Constipation  depraves  the 
general  health,  and  dyspepsia  interferes  with  the  generous  diet  that  is  so  needful 
in  the  asthenic  cases.  The  correction  of  these  difficulties  may  do  more  good  than 
any  local  treatment  for  the  arthritis. 

A  short  space  may  be  devoted  to  a  condition  in  childhood  looked  upon  by 
many  as  a  form  of  rheumatoid  arthritis,  but  first  clearly  defined  by  Dr.  G.  F. 
Still.  It  is  a  multiple  peri-articular  arthritis  with  enlargement  of  the  spleen  and 
lymphatic  glands.  The  condition  is  a  very  striking  one,  and  the  recurrent 
attacks  of  fever  are  most  suggestive  of  the  presence  of  an  infection.  The  writer 
more  than  once  has  seen  such  a  case  improve  in  the  most  remarkable  way  while 
under  careful  supervision,  and  then,  without  any  discoverable  reason,  drift  back 
to  the  last  stage  of  emaciation  and  illness  while  in  precisely  similar  surroundings. 
The  prognosis  of  the  characteristic  cases  is  very  serious ;  great  crippling 
results,  and  death  may  occur.  In  some  of  the  fatal  cases,  general  pericardial 
adhesion  has  been  found,  the  result  of  a  pericarditis  unsuspected  during  life. 
No  treatment  appears  certainly  to  influence  their  course,  although  liquid 
paraffin  and  other  intestinal  disinfectants  seemed  to  do  good  in  a  few  cases 
for  a  while. 

There  appear  to  be  transitional  cases  of  less  severity,  some  of  them  approaching 
closely  the  character  of  subacute  rheumatism,  and  these  may  improve  after 
several  years,  and  eventually  make  a  good  recovery.  Some  of  them  seem  to 
the  writer  to  be  associated  with  damp,  low-lying  districts,  and  this   danger,  if 


RHEUMATOID     ARTHRITIS  459 

corrected,  favours  the  outlook.     The  first  step  that  he  would  insist  upon  in  any 
case  of  this  kind  would  be  removal  from  damp  surroundings. 

The  Influence  of  Treatment  upon  Rheumatoid  Arthritis. — This  is  a  question 
of  much  importance,  and  there  can  be  little  doubt  that  the  great  emphasis  that 
at  the  present  time  is  laid  upon  the  infective  element  in  the  condition  must 
eventually  lead  to  much  clearer  views  upon  the  value  of  numerous  methods 
now  in  use. 

If  the  condition  is  infective,  there  are  two  main  indications  for  treatment :  one 
to  attack  the  infection,  the  other  to  promote  the  constitutional  resistance.  The 
first  aims  at  destroying  the  focus  of  infection  and  counteracting  the  morbid 
effects  already  at  work.  It  is  clear  from  the  pathology  of  the  disease  that 
many  of  the  changes  are  inflammatory  in  nature,  and  run  through  the  usual 
phases  of  such  changes.  There  is  the  period  of  activity  and  the  period  of  retro- 
gression, and  that  of  more  or  less  perfect  healing.  Unfortunately,  in  many 
cases  we  do  not  know  the  nature  of  the  infection,  and  the  prognosis  is  the  more 
serious  on  this  account.  It  is  rational  to  remove  possible  foci  and  to  give  proper 
rest  to  the  tissues  while  the  infection  is  active.  It  is  also  rational  to  treat  cases 
with  vaccines  if  the  nature  of  the  infection  is  known,  and  this  method  is  really 
one  of  undoubted  efficacy  ;  but  seeing  that  vaccines  are  often  used  without  a  con 
viction  of  the  nature  of  the  infection,  and  only  on  the  hypothesis  that  some  focus 
which  has  been  singled  out  contained  the  real  agent,  the  prognosis  in  many  cases 
is  not  certainly  improved,  and  more  accurate  details  are  still  needed  before  we 
can  estimate  the  improvement  in  the  outlook  resulting  from  such  methods.  The 
evidence  of  reliable  data  is  urgently  required.  If  the  infection  is  thought  to  be 
located  in  the  large  bowel,  then  high  douches  are  rational ;  but  here  again  there 
seems  good  reason  to  think  that  the  intestinal  symptoms  are  frequently  not  the 
primary  focus,  but  are  a  part  of  the  general  disorder,  and  so  again  the  prognosis 
from  this  point  of  view  remains  uncertain  until  we  can  get  more  reliable  data. 

There  are  numerous  methods  of  treatment  directed  to  the  damaged  joints.  It 
cannot  be  too  much  insisted  that  if  the  disorder  is  infective  these  methods  do  not 
deal  with  the  cause  of  the  disease.  When  Nature  is  conquering  the  local  infec- 
tions, then  these  measures,  properly  applied,  favour  the  rapidity  and  completeness 
of  recovery  ;  but  it  is  difficult  to  see  how  radiant  heat,  or  massage,  or  Aix  or 
Vichy  douches,  or  peat  or  fango  baths,  can  do  more  than  assist  a  process  of 
recovery — and  to  this  extent  improve  the  prognosis.  Whether  kataphoresis  has 
real  power  in  directly  attacking  local  foci  of  infection  must  still  be  regarded  as 
uncertain. 

When  we  turn  to  internal  remedies,  we  see  once  more  that  some  are  used  to 
attack  the  supposed  site  of  infection,  as,  for  example,  guaiacol  carbonate  and 
other  intestinal  disinfectanis,  while  others  are  used  to  strengthen  or  alter  the 
patient's  general  condition.  Among  these  latter  remedies  we  find  alteratives, 
including  mineral  waters,  and  tonics,  such  as  iron  and  arsenic,  quinine,  etc. 

In  such  diverse  conditions  as  those  we  are  considering,  it  is  eminently  possible 
that  in  some  cases  of  the  so-called  '  rheumatic  gout  '  class  internal  treatment 
by  drugs  or  by  waters  may  be  helpful,  for  in  these  metabolism  seems  certainly  at 
fault ;  on  the  other  hand,  where  the  infection  seems  predominant,  it  is  difficult 
to  see  how  water-drinking  will  help,  unless  the  minute  traces  of  radium  are  to  be 
looked  upon  as  antibacterial.  Radium  water  has  come  into  prominence  in  the 
last  few  years,  and  the  latest  accounts  give  a  bright  vision  of  its  future.  The 
writer  cannot  yet  be  in  a  position  to  make  a  statement  as  to  the  influence  of  this 
treatment  upon  the  prognosis.  When  we  realize  how  our  spas  have  clung  to  the 
minute  traces  that  are  found  in  their  natural  waters,  we  may  well  wonder  whether 


46o  •  INDEX     OF     PROGNOSIS 

'  Ichabod  '  is  now  ringing  in  their  ears.  Doubtless,  the  value  of  this  treatment 
will  soon  be  appraised  ;  but  at  the  time  of  writing  there  seems  to  be  no  justifica- 
tion— in  what  is  striving  to  be  a  balanced  opinion  upon  prognosis — for  the 
assertion  that  a  great  advance  has  been  made  in  the  management  of  the  disease . 
We  can  understand  how  much  the  prognosis  may  be  improved  if,  with  clear 
evidence  of  damp  and  cold  surroundings,  we  are  able  to  substitute  warmth, 
dryness,  and  cheerful  company,  for  then  we  are  certainly  assisting  the  best  of  all 
healers — Nature . 

There  is  another  group  of  remedies  which  aim  at  altering  the  nervous  influences, 
and  success  must  largely  depend  upon  how  much  of  truth  there  is  in  the  view 
that  rheumatoid  arthritis  is  largely  the  result  of  disordered  innervation.  Such 
methods  as  blistering  the  spine  come  into  this  category.  We  cannot  escape 
from  the  fact  that  some  have  had  great  successes,  and  thus  bettered  the  prog- 
nosis ;  yet  we  have  met  with  patients  who  have  fled  from  the  stringent  blister 
none  the  better,  but  rather  the  worse.  Here,  again,  we  need  more  definite 
details  and  indications  before  we  can  appraise  the  value  of  such  methods  in  the 
question  of  prognosis. 

One  point  stands  out  clearly  with  regard  to  treatment,  and  this  is  that  the 
prognosis  is  not  infrequently  made  decidedly  worse  by  over-zeal.  If  we  are  to 
accept  as  a  working  basis  that  the  condition  is  an  infection,  the  patient  must  be 
studied  as  an  individual,  and  the  stage  of  the  infective  process  must  be  recognized, 
and  this,  too,  with  the  humbling  knowledge  of  our  ignorance  of  the  exact  nature 
of  the  infection.  Forgetfulness  of  these  points  leads  to  our  seeing  a  weakly 
patient  reduced  to  the  last  stage  of  debility  by  an  avalanche  of  therapeutic 
methods,  some  of  them  not  apparently  rational,  and  then  the  outlook  is  definitely 
rendered  more  gloomy.  There  can,  ho\<fever,  be  but  little  doubt  that,  with  the 
more  complete  understanding  of  rheumatoid  arthritis,  the  prognosis  is  slowly 
improving,  and  that  the  most  encouraging  field  for  this  improvement  lies  in  the 
determined  study  of  possible  sites  of  infection,  and  in  the  adaptation  of  the 
various  imperfect  remedies  at  present  at  our  disposal  to  the  particular  individual, 
and  to  the  particular  phase  of  the  illness.  What  lamentable  results  may  follow 
a  restricted  diet  in  a  severe  case  of  rheumatoid  arthritis  !  All  the  more  lament- 
able, may  I  add,  because  we  cannot  picture  clearly  in  our  mind  any  real 
justification  for  such  a  step. 

In  writing  this  imperfect  article  upon  the  prognosis,  no  attempt  has  been  made 
to  define  the  lesion  in  rheumatoid  arthritis,  or  to  differentiate  the  various  forms. 
Excluding  gonorrhoeal  affections,  the  group  of  cases  of  obstinate  non-suppurative 
arthritis  has  been  considered  as  a  whole,  and  emphasis  alone  been  laid  upon  the 
evidence  of  general  toxaemia  on  the  one  hand,  and  gross  articular  lesions  upon 
the  other  :  both  elements  of  first  importance  in  prognosis,  whatever  the  exact 
nature  of  their  causation.  It  is  clear  that  in  the  future  we  want  more  definite 
data  for  our  guidance.  Thus,  for  example,  we  want  a  number  of  carefully 
recorded  cases  in  which  the  influence  of  the  treatment  of  pyorrhoea  alveolaris  has 
been  studied.  A  clear  statement  of  the  condition  before  this  treatment,  together 
with  the  after-history,  whether  encouraging  or  not,  would,  as  the  cases  multiply, 
prove  of  great  value.  The  same  would  apply  to  the  various  vaccines,  and  to  the 
influence  of  change  of  climate  and  surroundings.  It  appears  to  the  writer  that 
data  of  this  kind,  however  disappointing,  must  give  assistance,  and  already  we 
are  much  indebted  to  Dr.  Strangeways  and  his  colleagues  for  their  work  in  this 
direction.  The  writer  feels  that  he  will  touch  a  chord  of  sympathy  in  the 
reader  when  he  concludes  with  the  statement  that  at  present  the  vast  number  of 
remedies  suggested  for  '  rheumatoid  arthritis '  are  almost  as  difficult  to  handle 
as  the  disease  itself.  F.  J.  Poynion. 


RINGWORM  461 


RICKETS. — Rickets  is  a  disease  which  invariably  gets  well  when  the  patient 
passes  from  infancy  to  childhood,  and  although  the  older  textbooks  describe  a 
condition  called  '  late  rickets,'  which  is  said  to  be  a  relapse,  it  is  very  doubtful 
if  there  is  any  real  relation  between  them.  It  is  customary,  at  the  present  time, 
to  speak  of  the  spinal  curvatures,  coxa  vara,  genu  valgum,  fiat-foot,  and  similar 
deformities  as  '  static,'  not  rickety. 

On  the  other  hand,  although  the  rickets  passes  away,  the  deformities  of  the 
bones,  if  of  marked  degree,  will  be  permanent.  Thus  if,  in  a  young  child,  the 
knees  are  two  or  more  inches  apart  with  the  ankles  touching,  it  is  probable  that 
the  condition  of  bow-legs  will  persist  throughout  life,  if  not  remedied  by  opera- 
tion. There  is,  however,  a  not  very  uncommon  form  where  a  child  is  born  with 
the  legs  slightly  bent,  and  there  is  a  decided  separation  at  the  knees  throughout 
infancy,  which  only  gets  well  when  the  art  of  walking  has  been  thoroughly 
learned  ;  it  is  important  to  distinguish  this  from  genuine  rickets,  no  other  signs 
of  which  are  present. 

The  most  serious  consequences  of  rickets  are  due  to  the  coincident  affection 
of  the  nervous  system.  Tetany  (carpo-pedal  spasm)  usually  indicates  grave 
malnutrition.  Convulsions  in  children  are  usually  associated  with  rickets,  and 
are  occasionally  fatal.  Laryngismus  stridulus,  though  alarming,  very  seldom 
threatens  hfe  unless  there  is  an  actual  laryngitis  present.  A.  Rendle  Short. 

RINGWORM:— 

Scalp. — The  prognosis  in  ringworm  of  the  scalp  has  been  revolutionized  by 
the  introduction  of  the  ;i;-ray  treatment.  Under  the  old  conditions — repeated 
shaving  of  the  scalp  and  the  application  of  ointments,  lotions,  etc. — it  was 
common  to  meet  with  cases  of  two  years'  duration,  even  when  every  care  was 
taken,  and  the  ointments,  etc.,  were  applied  by  skilled  persons.  The  writer  has 
seen  cases  in  which  the  endothrix  fungus  has  been  present  for  five  years.  The 
average  duration  of  the  residence  of  children  in  schools  specially  devoted 
to  the  treatment  of  ringworm,  in  Paris  (Sabouraud)  and  in  this  country,  was 
eighteen  months.  Under  ,r-ray  treatment,  when  complete  epilation  has  been 
obtained,  the  scalp  is  usually  free  from  infection  in  four  or  five  weeks.  Time  has 
to  be  allowed  for  the  hair  to  grow,  and  the  average  period  during  which  a  child 
need  be  kept  from  school  is  about  three  months.  Where  a  cap  can  be  worn,  the 
child  may  return  to  its  usual  surroundings  immediately  the  infected  hair  has 
fallen,  that  is,  in  about  five  or  six  weeks. 

Re-infection  must  be  guarded  against  by  the  complete  sterilization  or  destruc- 
tion of  all  infected  caps,  hats,  etc. 

Favus  of  the  Scalp  does  not  give  quite  such  good  results,  because  in  severe  cases 
the  true  skin  is  sometimes  involved,  and  prolonged  treatment  after  epilation 
may  be  required. 

Glabrous  Skin. — The  prognosis  is  usually  extremely  good.  With  the  removal 
of  the  infected  epidermis  by  the  use  of  iodine,  or  the  application  of  ointments 
of  chrysarobin,  or  of  benzoic  and  salicylic  acids  in  combination,  as  suggested  by 
Whitfield,  a  cure  can  usually  be  effected  in  a  couple  of  weeks.  Care,  of  course, 
must  be  taken  that  there  is  no  re-infection.  The  so-called  eczema  marginatum 
of  the  groin  is  a  variety  of  ringworm,  and  this  readily  responds  to  treatment, 
especially  to  the  benzoic  and  salicylic  acid  ointment.  Ringworm  of  the  toes, 
which  often  occurs  in  association  with  the  eczema  marginatum  of  the  groin,  is 
less  easy  to  cure.  The  infection  persists  between  the  toes,  and  especially  in  the 
thickened  epidermis  on  the  plantar  surface  at  the  junction  of  the  toes  with  the 
sole.  Recurrences  in  this  site  are  very  common,  and  in  some  cases,  where  the 
nature  of  the  condition  has  not  been  recognized,  the  trouble  may  continue  for 
several  years. 


462  INDEX     OF     PROGNOSIS 

Nails. — Ringworm  of  the  nails  may  persist  for  years.  The  fungus  is  commonly 
of  the  endothrix  type,  and  cure  is  often  very  difficult.  The  fungus  involves  the 
ungual  plate  and  the  root  of  the  nail,  and  forms  thick  masses  of  scale  under  its 
distal  end.  Many  months'  treatment  by  scraping,  and  the  constant  application 
of  antiseptics  such  as  iodine  or  mercurials,  may  effect  a  ciare.  Norman  Walker 
has  had  better  results  by  soaking  the  nail  in  Fehling's  solution  until  it  is  softened, 
and  then  dressing  the  base  with  copper  sulphate  solution.  Even  complete 
avulsion  of  the  infected  nails  and  the  application  of  strong  antiseptics  may  be 
insufficient  to  bring  about  a  cure  ;  the  writer  has  a  case  in  which  the  infection 
has  persisted  for  several  years  in  spite  of  the  fact  that  the  nails  have  been  renaoved 
on  two  occasions.  Where  the  infection  exists  for  a  long  time  in  the  nails  it  is 
common  to  find  the  glabrous  skin  attacked  from  time  to  time,  and  this  point 
should  be  borne  in  mind  in  cases  of  recurrent  attacks  of  tinea  of  the  smooth  skin. 

Beard. — If  the  affected  parts  are  thoroughly  freed  from  hair  by  the  forceps,  or 
still  better  by  the  x  rays,  and  then  dressed  with  antiseptic  ointments,  the  results 
are  usually  satisfactory.  In  the  writer's  experience,  the  more  suppurative  the 
ringworm  of  the  beard,  the  speedier  is  the  cure.  It  must  be  remembered  that 
these  cases  closely  simulate  sycosis  of  coccogenic  origin,  which  is  notoriously 
difficult  to  cure,  /.  H.  Sequeira. 

RODENT  ULCER.  —  The  prognosis  in  rodent  ulcer  depends  upon  early 
diagnosis.  So  long  as  the  lesion  is  limited  to  the  skin  and  subcutaneous  tissue, 
there  are  several  methods  of  treating  it  successfully.  Radium  therapy  gives 
excellent  results  ;  I  have  cases  of  rodent  ulcer  treated  by  radium  which  have 
been  free  from  recurrence  for  ten  years.  The  proper  application  of  the  x  rays, 
with  or  without  preliminary  curettage  of  the  raised  edge  of  the  ulcer,  gives 
similar  results.  Cases  treated  eleven  and  twelve  years  ago  are  still  free  from 
recurrence. 

Radium  has  occasionally  proved  successful  when  the  x  rays  have  failed  to  bring 
about  a  cure,  and  in  the  writer's  opinion  there  are  cases,  especially  where  ulcera- 
tion preponderates  or  there  is  deep  infiltration,  in  which  the  converse  holds  true. 
In  all  cases  treated  by  radiuna  and  by  the  x  rays,  the  best  results  are  obtained 
when  the  lesion  re-acts  rapidly.  If  treatment  has  to  be  repeated  again  and  again, 
the  prognosis  is  not  satisfactory. 

Complete  excision  of  a  superficial  rodent  ulcer,  with  a  good  margin  of  healthy 
skin  around  and  below  the  lesion,  gives  admirable  results  ;  but  where  the  ulcer 
is  near  the  orbit,  and  particularly  at  the  inner  canthus,  the  operator  often  errs  by 
removing  too  little,  and  recurrences  are  inevitable. 

At  the  second  International  Surgical  Congress,  where  the  writer  had  the 
honour  of  presenting  the  rapport  on  radio-therapy,  he  recorded  an  average  of 
40  per  cent  of  recurrences  after  treatment  by  the  x  rays.  The  statistics  of 
operation  were  almost  identical.  A  larger  experience  has  shown  that  with  the 
proper  selection  of  cases  for  radiotherapy,  and  improvements  in  technique, 
especially  in  the  giving  of  massive  doses  through  appropriate  screens,  these 
results  have  been  materially  improved. 

When  a  rodent  ulcer  has  involved  cartilage  or  bone,  or  when  the  orbital  cavity 
has  been  invaded,  the  prospects  of  complete  cure  are  more  remote.  Thorough 
and  early  clearing  out  of  the  orbit  will  often  save  the  patient  for  some  years. 
Removal  of  the  maxilla,  when  the  disease  has  involved  that  bone  and  the 
accessory  sinuses,  may  be  necessary.  In  some  cases,  a  judicious  combination 
of  operation  with  radium  and  radio-therapy  may  effect  a  cure,  but  it  is 
difficult  to  remove  entirely  the  deeper  foci  of  the  disease  without  producing 
grave  mutilation. 


SALPINGITIS  463 

The  prognosis  as  regards  duration  of  life  is  not  as  serious  as  one  would  imagine, 
for  patients  often  live  for  many  years  with  a  hideous  cavity  in  the  face.  The 
writer  has  seen  one  such  of  forty  years'  duration.  A  fatal  termination  is  brought 
about  by  septic  infection  of  the  sinuses  of  the  skull,  meningitis  from  extension  to 
the  cranial  cavity,  general  sepsis,  and  exhaustion.  Constant  care  in  preventing 
septic  infection,  by  the  application  of  antiseptic  dressings,  irrigation,  etc.,  alone 
can  prevent  these  dangerous  complications. 

Mention  should  be  made  of  the  use  of  carbon-dioxide  snow  in  the  treatment 
of  superficial  rodent  ulcer.  Satisfactory  results  are  often  obtained,  but  relapses 
are  more  common  than  with  radium  or  x  rays.  On  several  occasions  the  writer 
has  had  to  apply  radium  after  failure  to  cure  a  rodent  ulcer  with  the  solid  carbon 
dioxide. 

Gray  recently  showed  a  case  of  extensive  disease  in  which  an  admirable  result 
had  been  obtained  by  the  revival  of  an  old  method  of  treatment,  viz.,  the  applica- 
tion of  arsenical  paste.  /.  H.  Seqtteira 

RUBELLA  (GERMAN  MEASLES). — The  prognosis  in  this  disease  is  almost 
invariably  excellent.  I  have  met  with  but  i  death  in  between  300  and  400 
cases.  Corbin  has  reported  that  there  was  not  a  single  death  amongst  1523 
consecutive  cases  admitted  to  the  London  Fever  Hospital  during  the  twenty-one 
years  1887  to  1907. 

Complications  are  rare.  I  have  twice  observed  otitis  media.  The  fatal  case 
referred  to  above  occurred  in  a  boy,  age  3,  who  succumbed  to  acute  cardiac 
dilatation  following  a  slight  attack  of  arthritis.  E.  W.  Goodall. 

RUPTURED  VISCERA. — {See  Abdominal  Injuries.) 

SALPINGITIS. — From  the  point  of  view  of  prognosis,  a  distinction  is  made 
between  chronic  non-suppurative  inflammations  of  the  tube  and  ovary  and  the 
ordinary  pyogenic  suppurative  conditions  which  are  considered  under  the 
heading  pyosalpinx. 

Salpingo-oophoritis. — -There  is,  probably,  no  more  difficult  problem  in  gynae- 
cology than  in  a  given  case  of  salpingitis  to  form  an  idea  as  to  the  end -results. 
In  the  majority,  almost  all  information  is  to  be  gained  from  the  record  of  the 
subjective  symptoms,  and  very  little  from  physical  signs,  so  that  errors  and 
uncertainties  of  diagnosis  must  be  common ;  although  the  symptoms  and 
general  reaction  to  an  inflammation  of  the  appendages  may  seem  comparatively 
trivial,  yet  the  far-reaching  results  of  such  a  condition  will  make  it  necessary 
that  a  guarded  prognosis  be  given,  not  so  much  concerning  the  immediate  future 
as  the  end-results.  In  fact,  the  cases  showing  acute  initial  illness  requiring 
active  treatment,  for  that  very  reason  often  do  better  in  the  long  run  than 
the  subacute  forms. 

The  Infecting  Organism. — Some  difference  in  prognosis  might  be  expected 
according  to  the  infection.  In  some  measure  this  is  probably  true  ;  but  the 
difficulty  of  diagnosing  the  nature  of  the  infecting  agent,  in  large  part  due  to 
the  similarity  of  symptoms  irrespective  of  the  causal  agent,  very  frequently 
renders  such  information  valueless.  The  tuberculous  lesion  is  usually  very 
chronic,  commonly  occurs  in  young  unmarried  or  non-parous  women,  and  is 
only  temporarily  relieved  by  prolonged  palliative  treatment.  In  gonococcal 
lesions,  it  is  currently  believed  that  with  one  tube  infected  the  opposite  tube 
will  be  likely  to  become  inflamed.  Also  in  acute  gonorrhoeal  forms,  one  is 
rarely  in  fear  that  general  peritonitis  will  supervene. 

An  inflammation  following  an  abortion,  or  occurring  during  the  puerperium, 


4-54  INDEX     OF     PROGNOSIS 

is  usually  of  streptococcic  nature,  and  produces  a  condition  of  pehdc  perito- 
nitis— a  definite  clinical  condition  known  as  perimetritis,  ending  in  most  cases  in 
partial  or  complete  recover)^  or  more  rarely  passing  on  to  a  pyosalpinx. 

Effects  of  Salpingitis. — The  effects,  more  especially  the  remote  effects,  may 
be  enumerated  and  considered  irrespective  of  the  causal  agent.  In  the  first 
place,  there  is  no  doubt  that  pelvic  adhesions  in  the  majority  of  cases  owe  their 
origin  to  a  previous  salpingitis.  These  adhesions  may  be  symptomless  and 
only  discovered  during  the  course  of  other  operative  procedures  ;  but  generally 
they  give  rise  to  ill-defined  symptoms  of  pain,  varying  greatly  in  intensity,  and 
often  causing  considerable  distress.  The  inability  to  recognize  such  adhesions 
on  examination,  often  leads  to  a  diagnosis  of  neurosis,  and  to  lack  of  success  in 
treatment.  Again,  conditions  frequently  associated  with  salpingitis  are  the 
retro-displacements  of  the  uterus,  especially  of  the  fixed  variety.  Or  the 
development  of  a  hydrosalpinx  may  give  rise  to  pressure  symptoms,  or  cause 
displacement  of  the  uterus  or  rectum. 

The  Results  of  Treatment. 

Expectant. — In  the  acute  varieties  of  salpingitis,  the  recognized  form  of  treat- 
ment consists  in  absolute  rest,  douches,  and  saline  purgation.  Findley^  quotes 
Fraub,  of  Amsterdam,  as  reporting  cures  in  70  per  cent  of  cases  as  a  result  of 
this  mode  of  treatment.  The  cures,  however,  were  not  absolute,  as  in  a  limited 
number  there  were  relapses ;  but  he  maintains  that  at  least  50  per  cent  of  cases 
of  salpingitis  require  no  operative  treatment.  The  average  duration  of  treat- 
ment under  this  expectant  method  was  six  weeks  ;  however,  in  some  cases  it 
was  as  short  as  three  weeks,  while  in  others  it  extended  to  as  many  months. 
Unfortunatety,  it  is  only  the  better  classes  who  are  able  to  submit  to  the  longer 
periods  of  rest. 

Finally,  there  is  no  doubt  that  if  the  treatment  is  persisted  in,  there  is  a  very 
good  chance  of  recovery.  It  has  not  infrequently  happened  that  patients  who 
have  been  recommended  to  submit  to  operation  and  who  have  been  pronounced 
to  be  very  unlikely  to  conceive,  have  yet  recovered  and  borne  children. 

Operative. — In  the  chronic  forms  of  salpingitis,  which  do  not  react  to  medical 
means,  and  in  which  the  symptoms  indicate  the  necessity  for  further  measures, 
the  only  alternative  lies  in  surgical  intervention.  The  immediate  operative 
results  are  uniformly  good,  as  is  seen  in  the  accompanying  figures  taken  from 
the  annual  reports  for  the  years  1912  and  1913  of  the  Chelsea  Hospital  for 
Women. 2  Number  of  cases  operated  on  in  1912,  61 — no  deaths  ;  in  1913,  55 
— no  deaths  ;    a  total  of  116,  with  no  deaths. 

The  operative  risks  are  therefore  not  great ;  but  it  is  necessary  to  consider 
how  often  this  treatment  leads  to  complete  recover}'.  It  is  undoubtedly  true 
that  in  a  few  instances  relief  does  not  follow  operative  measures  ;  but  this  is 
often  the  result  of  omitting  to  remove  the  uterus  as  well  as  the  tubes,  or  due 
to  faults  in  technique,  which  in  the  near  future  may  be  much  improved. 

Pyosalpinx. — The  operative  treatment  of  pyosalpinx  shows  results  very 
different  from  those  in  chronic  salpingo-oophoritis.  It  is  in  fact  one  of  the 
most  serious  operations  in  g^maecology,  the  mortality  being  only  exceeded  by 
that  of  Wertheim's  hysterectomy  for  carcinoma  of  the  cervix.  Thus,  in  the 
returns  of  the  Chelsea  Hospital  for  Women^  for  the  last  two  years,  operations 
for  pyosalpinx  were  undertaken  in  31  cases,  with  5  deaths,  a  mortality  of  161 
per  cent.  Such  a  death-rate  appears  exceedingly  high ;  but  many  of  the  cases 
were  very  seriously  ill.  Injury  to  the  bowel  during  the  course  of  operation 
accounted  for  a  certain  number  of  deaths. 

In  those  cases  recovering,  there  is  a  strong  likelihood  of  adhesions  forming 
between  the  peritoneally  denuded  surfaces  of  the  pelvis  and  its  viscera  ;    also 


SCARLET     FEVER 


465 


when  the  uterus  is  preserved,  unless  the  precaution  of  fixing  it  to  the  abdominal 
wall  be  taken,  there  is  much  likelihood  of  a  fixed  retroversion  occurring  during 
convalescence. 

Tuberculous  Salpingitis. — With  regard  to  the  operative  treatment  of  this 
condition,  the  results  seem  to  be  uniformly  good,  provided  the  tuberculous 
material  be  all  removed.     No  other  measure  can  offer  equally  good  results. 

References. — ^Diseases  of  Women,  1911,  467  ;  ^Chelsea  Hospital  for  Women, 
Annual   Reports,  1912  and  1913.  Brvden  Glendining. 

SARCOMA  OF  BONE.— (See  Bone  Tumours.) 

SCARLET  FEVER. — It  will  be  convenient  to  consider  the  question  of  the 
prognosis  of  this  disease  under  the  following  heads :  (i)  Age  ;  (2)  Sex  ;  (3) 
Severity  of  attack  ;    (4)  Special  symptoms  ;    (5)  Complications. 

I.  Age. — During  the  years  1900  to  1909,  153,553  patients  suffering  from 
scarlet  fever  were  admitted  into  the  hospitals  of  the  Metropohtan  Asylums 
Board.     The  fatality  at  the  different  ages  is  shown  in  the  following  table  : — 

Fatality  according  to  Age. 


Fatality        | 

Fatality 

Fatality 

per  cent        | 

per  cent 

per  cent 

0-1 

14-7 

0-5 

6-3 

25-30 

1-6 

1-2 

11-1 

5-10 

1-7 

30-35 

1-5 

2-3 

8-0 

10-15 

0-9 

35-40 

2-8 

3-4 

5-5 

15-20 

1-1 

40  and  over 

2-2 

4-5 

3-4 

20-25 

1-7 

All  age.? 

3-0 

It  will  be  seen  that,  under  fifteen  years  of  age,  the  younger  the  patient  the 
greater  is  the  chance  of  death.  The  first  three  years  of  hfe  are  the  most  dan- 
gerous. 

2.  Sex. — The  fatality  amongst  males  was  slightly  higher  than  amongst 
females  :  for  all  ages,  it  was  3-2  per  cent  for  males  and  2-8  for  females  ;  under  five 
years  of  age,  it  was  6 '7  for  males  and  5-9  for  females. 

3.  Severity  of  Attack. — It  is  convenient,  for  the  purpose  of  description,  to 
divide  cases  of  scarlet  fever  into  three  classes  :  the  malignant,  or  toxic  ;  the 
anginoiis,  or  septic  ;  and  the  benign,  or  simple.  The  fatality  of  an  epidemic  or 
group  of  cases  will  depend,  partly  upon  the  proportion  of  each  of  these  three 
groups,  and  partly  upon  the  proportion  of  children  of  tender  years.  Malignant 
scarlet  fever  is  extremely  fatal  ;  very  occasionally  an  adult  will  recover  ;  but  I  do 
not  remember  ever  to  have  seen  a  case  amongst  children  under  ten  years  of 
age  which  was  not  fatal.  In  this  form  of  the  disease  serious  symptoms  come  on 
very  rapidly,  and,  in  children,  death  takes  place  within  four  days.  A  feature  of 
malignant  scarlet  fever  is  the  slightness  of  the  faucial  inflammation.  But 
usually  the  temperature  runs  high,  the  rash  is  vivid,  the  pulse  very  frequent 
(150  per  minute  or  more),  the  respiration  sighing,  and  the  skin  and  mucous 
membranes  dusky.  The  patient  is  prostrate,  delirious  or  comatose,  and  vomits 
frequently. 

Benign  scarlet  fever,  on  the  other  hand,  is  never  fatal,  unless  through  some 
complica^tion  (e.g.,  nephritis)  ;    and  then  but  rarely. 

Most  of  the  deaths  in  scarlet  fever  are  connected  with  the  faucial  lesions  of  the 
anginous  variety,  and  these  may  assume  various  forms.  Briefly,  it  may  be 
stated  that  the  more  extensive  the  inflammation  and   the  more  extreme  the 

30 


466  INDEX     OF     PROGNOSIS 

swelling,  the  graver  is  the  prognosis,  because  sloughing  or  ulceration,  more  or  less 
widespread,  is  sure  to  result,  conditions  which  are  very  favourable  to  the  develop- 
ment of  septicaemia  or  pyaemia.  There  is  a  variety  of  the  disease,  not  often  met 
with,  which  holds  an  intermediate  place  between  the  benign  and  the  anginous 
forms  in  respect  of  the  prognosis.  I  refer  to  what  is  known  as  the  typhoid  form. 
In  this,  the  temperature  remains  raised  for  three  or  four  weeks,  and  yet  the  faucial 
lesions  are  moderate  in  severity.  If  death  takes  place,  it  is  nearly  always  due  to 
some  complication. 

It  is  a  prevalent  idea  that  an  attack  of  scarlet  fever  occurring  in  a  pregnant 
or  recently  delivered  woman  is  more  often  than  not  of  unusual  severity.  But 
my  experience  points  in  the  opposite  direction.  During  the  twenty-one  years, 
1892  to  191 2,  there  have  been  at  the  Eastern  Hospital  40  cases  of  women  who 
were  attacked  by  scarlet  fever  just  before  or  just  after  delivery.  In  only  4 
of  the  cases  was  the  attack  severe,  and  in  only  i  could  death  be  attributed 
to  the  scarlet  fever.  There  were  four  other  fatal  cases  amongst  these  women, 
but  in  all  of  these  there  was  present,  before  the  symptoms  of  scarlet  fever  set  in, 
a  septic  condition  due  to  retained  placenta,  laceration  of  the  uterus,  etc.,  which 
was  quite  sufficient  to  account  for  the  fatal  event. 

4.  Symptoms  of  Special  Seriousness.  —  These  are  :  repeated  vomiting ; 
continuous  excessive  frequency  of  the  pulse  (over  150,  especially  in  adults)  ; 
sighing  respiration  ;  coma  ;  a  prolonged  high  temperature  ;  prolonged  delirium 
and  restlessness  ;  a  dusky  or  cyanotic  appearance  of  the  skin.  These  symptoms 
are  most  often  met  with  in  malignant  scarlet  fever,  but  they  may  be  observed  in 
some  cases  of  the  anginous  form.  To  what  has  been  stated  above  concerning 
the  prognosis  in  the  latter,  it  niay  be  added  that  if,  in  spite  of  the  return  of  the 
temperature  to  the  normal  and  the  improvement  in  the  faucial  lesion,  the  pulse- 
rate  remains  unduly  frequent,  the  patient  continues  to  waste,  and  there  is  loose- 
ness of  the  bowels  and  occasional  vomiting,  the  prognosis  is  unfavourable. 

5.  Complications. — These  are  most  frequently  met  with  during  or  after  an 
attack  of  anginous  scarlet  fever.  Seldom  is  an  attack  of  the  malignant  variety 
of  sufficient  duration  to  allow  of  their  occurrence. 

Cervical  Cellulitis. — This  is  one  of  the  most  fatal  complications  ;  the  more 
extensive  it  is,  the  more  ominous  it  is.  Those  children  seldom  recover  in  whom 
the  cellulitis  involves  the  whole  of  the  neck  below  the  jaw,  from  one  ear  to 
the  other. 

Nephritis. — Marked  albuminuria  and  diminution  in  the  quantity  of  urine, 
occurring  during  the  first  week  or  two  of  an  attack  of  scarlatina  anginosa,  are  to 
be  regarded  with  apprehension ;  for  they  are  not  infrequently  the  sole  ex- 
pression of  a  particularly  severe  form  of  nephritis.  Should  there  also  be  coma  or 
semi-coma,  with  muscular  twitchings,  the  outlook  is  still  more  grave.  A  purpuric 
condition  supervening  at  any  stage  of  the  disease  is  nearly  always  serious. 

The  common  form  of  scarlatinal  nephritis,  that  which  is  a  sequel  rather  than  a 
complication  of  the  disease,  more  often  follows  a  severe  than  a  mild  attack. 
It  may  begin  abruptly,  with  vomiting,  pyrexia,  haematuria,  scantiness  of  urine, 
and  occasionally  a  rigor.  But  it  may  also  begin  insidiously,  with  little  else  but 
albuminuria.  On  the  whole,  the  more  abrupt  the  onset,  the  less  likely  is  the 
attack  of  nephritis  to  be  prolonged  ;  whereas  the  case&with  an  insidious  beginning 
are  usually  tedious.  The  duration  of  an  attack  of  nephritis  varies  from  three  to 
eight  or  ten  weeks.  The  vast  majority  of  the  cases  recover  completely  and  do 
not  become  chronic. 

It  is  not  often  that  the  renal  lesion  is  the  cause  of  death  ;  when  this  event 
occurs,  it  is  usually  due  to  some  such  intercurrent  affection  as  pneumonia  or 
pericarditis  ;    so  that  the  occurrence  of  these  complications  is  unfavourable. 


SCI  A  TIC  A  467 

The  fatality  of  nephritis  is  about  8  per  cent,  and  is  higher  among  children  than 
adults. 

Of  symptoms  that  are  due  to  the  nephritis  itself,  the  most  unfavourable  are 
drowsiness,  coma,  a  marked  diminution  in  the  amount  of  urine  excreted,  and 
extreme  anasarca.  The  last  symptom  is  seldom  met  with  in  cases  that  have 
been  brought  under  treatment  at  an  early  stage.  Convulsions,  though  serious, 
are  by  no  means  so  grave  as  the  symptoms  just  mentioned ;  they  are  prone  to 
arise  without  the  slightest  warning,  in  cases  which  are  by  no  means  severe  and 
are  apparently  progressing  favourably. 

The  incidence  of  nephritis  varies  considerably.  The  average  for  the  ten  years 
1900  to  1909  in  the  hospitals  of  the  Metropolitan  Asylums  Board  was  4-6  per 
cent  in  153,607  cases  of  scarlet  fever.  It  is  highest  in  children,  and  especially 
in  those  between  the  ages  of  five  and  ten  years,  and  of  the  male  sex. 

Rheumatism.— The  prognosis  of  the  articular  rheumatism  which  not  infre- 
quently follows  an  attack  of  scarlet  fever  is  usually  favourable.  It  is  not  often 
that  cardiac  complications  occur,  at  any  rate  in  those  cases  in  which  arthritis  is 
manifest.  There  are  reasons,  however,  for  thinking  that  endo-  or  pericarditis 
arises  in  the  course  of  scarlet  fever  more  often  than  is  supposed  ;  and  that 
they  are  either  overlooked,  or  do  not  give  rise  to  symptoms,  till  long  after  the. 
scarlatinal  attack  is  past. 

Pycemia. — This  is  an  extremely  unfavourable  complication  of  scarlet  fever. 

Laryngeal  Affection. — ^Such  an  event  is  seldom  met  with  except  in  the  anginous 
form  of  the  disease,  and  it  makes  the  outlook  grave.  Even  if  the  patient 
recovers,  a  more  or  less  pronounced  stenosis  of  the  larynx  remains. 

Otitis  Media. — The  prognosis  is  usually  favourable,  provided  that  the  appro- 
priate treatment  has  been  commenced  early.  But  this  complication  is  apt  to 
resist  treatment,  which  must,  therefore,  be  carried  out  with  unremitting  care  to 
prevent  the  occurrence  of  any  serious  impairment  of  hearing. 

Tuberculosis. — An  attack  of  scarlet  fever  will  often  have  a  most  prejudicial 
effect  on  patients  who  are  the  subject  of  tuberculous  lesions.  Not  only  is  the 
part  affected  by  tubercle  likely  to  become  worse,  but  nephritis  is  prone  to  occur 
and  to  be  prolonged.  E.   W.  Goodall. 

SCIATICA. — This  term  is  applied  to  pain  in  the  region  of  the  sciatic  nerve 
and  its  branches.  Sciatica  includes  both  sciatic  neuralgia  and  sciatic  neuritis, 
and  in  every  individual  case  we  have  to  decide  which  of  these  two  is  present. 

Many  cases  of  sciatic  neuralgia  occur  independently  of  any  affection  of  the 
nerve:  e.g.,  in  disease  of  the  vertebrae  (whether  tuberculous  or  arthritic),  in 
affections  of  the  sacro-iliac  joint  or  the  hip-joint,  in  diseases  of  the  femur  (tumours, 
osteomyelitis,  etc.),  in  intermittent  arterial  claudication,  etc.  In  other  cases, 
especially  in  gouty  and  rheumatic  subjects,  we  have  to  do  with  a  sciatic  neuritis, 
in  which  the  fibrous  sheath  of  the  nerve-trunk  becomes  thickened  and  inflamed. 

Sciatic  Neuralgia. — The  prognosis  of  sciatic  neuralgia,  secondary  to  disease  of 
other  structures — vertebrae,  pelvis,  sacro-iliac  joint  or  hip-joint,  femur,  etc., — 
depends  upon  the  possibility  of  relieving  the  primary  cause. 

Sciatic  Neuritis. — This  is  a  somewhat  obstinate  malady  ;  it  may  last  for 
months  or  even  years,  varying  in  its  intensity  from  time  to  time,  and  being 
specially  liable  to  relapses.  The  presence  of  muscular  atrophy,  and  the  diminu- 
tion or  loss  of  the  Achilles-jerk  in  the  affected  limb,  indicate  that  definite 
degenerative  changes  have  occurred  in  the  nerve  fibres.  Anaesthesia  in  the 
cutaneous  distribution  of  the  nerve  is  uncommon,  and  is  indicative  of  a  still  more 
severe  degree  of  degeneration.  Nevertheless,  the  ultimate  prognosis,  even  in  long- 
standing cases,  is  usually  favourable,  except  in  senile  and  debilitated  patients. 


468  INDEX     OF     PROGNOSIS 

Bilateral  sciatica  is  always  a  more  serious  affair.  It  may  be  due  to  diabetic 
neuritis,  or  it  may  be  symptomatic  of  gross  disease  elsewhere,  e.g.,  in  the  sacral 
region  of  the  spinal  cord  or  cauda  equina,  or  in  the  bones  of  the  vertebrae  or  pelvis. 

In  every  case  of  sciatic  neuritis,  rest  and  avoidance  of  violent  movement  are 
desirable.  Recent  cases  often  subside  rapidly  under  hot  local  applications  (e.g., 
hot  poultices,  radiant  dry  heat,  hot  mud-baths,  electric-light  baths,  hot  air,  etc.) 
combined  with  anti-gouty  or  anti-rheumatic  remedies,  as  the  case  may  be.  In 
other  cases,  excellent  results  are  obtained  by  counter-irritation  (e.g.,  by  iodine, 
fly-blisters,  or,  better  still,  by  a  Paquelin  cautery)  applied  to  the  tender  points 
along  the  course  of  the  nerve.  Electrotherapeutic  methods,  in  the  hands  of  an 
expert,  are  often  useful,  especially  the  employment  of  a  galvanic  current,  with  or 
without  ionization  by  various  drugs  ;  or  again  of  the  static  wave-current ;  or,  in 
chronic  cases,  of  static  sparks  along  the  course  of  the  nerve-trunk.  Sometimes 
obstinate  cases  of  sciatic  neuritis,  which  have  resisted  other  means  of  treatment, 
are  relieved  by  injecting  directly  into  and  around  the  nerve-sheath  large 
quantities  of  saline  solution  (50  to  100  c.c),  to  which  may  be  added  a  small 
proportion  of  an  analgesic  drug  (e.g.,  i  per  cent  eucaine)  ;  or  the  fluid  may  be 
injected,  in  smaller  quantity,  into  the  roots  of  origin  within  the  sacral  canal,  by 
means  of  so-called  epidural  injection  through  the  sacro-coccygeal  fontanelle. 
Cutting  down  upon  the  sciatic  trunk,  dissecting  it  out,  and  forcibly  stretching  it, 
had  a  vogue  some  years  ago,  but  is  rarely  prescribed  nowadays  ;  it  appears  to 
have  no  special  advantages  over  saline  injections.  Purves  Stewart. 

SCLEROSIS,  DISSEMINATED. — (See  Disseminated  Sclerosis.) 

SCOLIOSIS. — The  following  factors  govern  the  prognosis  in  scoliosis. 

Apart  from  treatment,  the  deformity  often  gets  worse  in  growing  patients  ; 
but  when  growth  ceases  it  is  usually  arrested.  There  is  no  tendency  to  natural 
cure.     The  patients  are  bad  subjects  for  chest  diseases  later. 

To  find  an  answer  to  the  question  as  to  what  benefit  may  be  expected  from 
treatment  by  exercises,  massage,  etc.,  the  patient's  spine  must  first  be  put  into 
the  best  possible  position  by  the  surgeon's  hands.  It  will  be  possible  to  make 
that  position  habitual  by  treatment  ;  but  if  the  hands  do  not  overcome  bony 
deformity,  the  exercises  will  not  do  so.  It  is  usually  safe  to  promise  relief  of 
pain  and  prevention  of  further  progress  of  the  scoliosis. 

Certain  other  factors  influence  the  outlook. 

1.  The  Cause. — If  there  is  a  contracted  chest,  unequal  length  of  the  legs,  or 
severe  muscular  paralysis,  not  much  can  be  done  to  straighten  the  spine. 

2.  The  Age  and  Duration. — Recent  cases  are  better  than  old-standing.  The 
younger  the  patient  the  worse  the  prognosis.  Children  under  six  or  seven  do 
badly. 

3.  The  Type  of  Patient. — Shy,  shrinking  girls,  who  will  not  try  to  '  stand  up 
like  a  soldier,'  and  are  careless  of  their  personal  appearance,  are  unfavourable 
subjects. 

4.  The  Degree  of  Deformity. — The  deviation  of  the  vertebrae  matters  more 
than  that  of  the  spinous  processes.  Fixed  bony  deformity  cannot  be  cured  ; 
but  with  the  same  initial  degree  of  deformity  there  is  much  variation  in  the 
results  of  treatment.     High  or  low  curves  in  the  spine  are  unfavourable. 

5.  The  Nature  of  the  Treatment. — In  early  cases,  without  bony  flxation  in  a 
bad  position,  exercises,  posture,  and  massage  give  the  best  results.  In  old,  fixed 
cases  it  will  be  necessary  to  supplement  this  by  a  supporting  jacket  to  relieve 
aching  pain. 

References. — Tubby,  Deformities,  including  Diseases  of  Bones  and  Joints,  1912  j 
Noble  Smith,  Curvature  of  the  Spine,  1896  ;   Roth,  Clin.  Jour.  1914,  144- 

A.  Rendle  Short.. 


SEPTICEMIA  469 

SCROTUM,  CARCINOMA  OF. — This  disease  is  uncommon,  except  in  sweeps 
and  tar-workers.  It  is  one  of  the  least  maHgnant  of  all  forms  of  carcinoma,  but 
we  have  very  little  in  the  way  of  exact  statistical  evidence  bearing  on  the  point. 
Patients  sometimes  present  themselves  who  have  already  had  the  growth  for 
years.     No  doubt,  apart  from  treatment,  it  would  always  be  fatal  at  the  last. 

The  Operation  Mortality  is  small.  Out  of  58  cases  at  St.  Bartholomew's 
Hospital,  2  died,  both  being  very  bad  subjects.  Probably  clearance  of  the  groin 
glands  would  slightly  increase  the  mortality. 

The  End-results  have  been  studied  by  Butlin.^  Excluding  2  cases  which  died 
from  the  operation,  and  2  more  in  which  the  glands  were  involved  but  not 
removed,  we  have  the  following  :  7  cases  recurred  ;  5  cases,  followed  one  to 
three  years,  are  well  ;    8  cases,  followed  over  three  years,  are  well. 

Even  amongst  the  recurrences,  a  second  operation  was  several  times  successful. 
It  is  true  that  recurrence  is  occasionally  very  late  ;  probably,  in  some  instances, 
it  is  really  a  new  cancer. 

We  have  no  figures  to  show  whether  it  is  wise  to  remove  the  groin  glands.  This 
was  done  in  some  of  Butlin's  cases,  but  not  in  all. 

Reference. —  ^Butlin,    Operathe  Sp.rgery  of  Malignant  Disease,   2nd  ed. 

A.  Rendle  Short. 

SCURVY. — Scurvy  is  not  nearly  so  common  as  formerly,  and  its  more  severe 
aspects  are  now  practically  never  seen  in  this  country.  In  the  eighteenth 
century  the  mortality  from  scurvy  was  appalling  ;  in  Lord  Anson's  voyage  round 
the  world  in  1 740-1 744,  380  out  of  510  seamen  died  of  the  disease.  Present-day 
mortality  in  this  country  is  well  under  i  per  cent.  Although  the  intimate  nature 
of  the  disease  is  not  yet  understood,  it  is  well  known  that  certain  simple  measures 
will  either  prevent  its  onset  or  cure  its  manifestations.  The  prognosis  depends, 
therefore,  mainly  upon  the  availability  of  the  means  of  suitable  treatment. 
Unless  the  patient  when  first  seen  is  dangerously  ill,  recovery  may  almost 
certainly  be  predicted.  The  most  important  danger  is  sudden  syncope.  This 
must  be  met  by  keeping  the  patient  absolutely  quiet  in  bed  for  a  week.  After 
that  period  the  danger  has  passed,  and  restoration  to  health  may  be  looked  for 
at  the  end  of  a  fortnight.  As  the  patient  improves,  a  striking  change  in  his 
aspect  will  be  noticed.  The  subcutaneous  and  intramuscular  indurations  clear 
away  ;  this  is  followed  by  a  return  to  normal  of  the  gums,  and  lastly,  by  a 
disappearance  of  the  petechise.  The  tendency  for  wounds  to  break  down  and 
ulcers  to  form  ceases  when  treatment  begins,  and  healing  is  rapid. 

When  scurvy  has  come  under  treatment,  the  only  danger  to  life,  apart  from 
the  possibility  of  syncope,  arises  from  the  existence  or  onset  of  a  complication. 
Pneumonia  is  thus  a  source  of  danger.  Pleurisy  and  pericarditis,  even  when 
the  effused  fluid  is  sanguineous,  usually  clear  up.  A  complication  such  as 
dysentery  may  cause  symptoms  to  persist.  Haemorrhage  is  not  usually  of 
serious  import  and,  apart  from  epistaxis,  is  uncommon.  G.  L.  Gulland. 

A  Goodall. 

SECONDARY  ANEMIA. — [See  ANiEMiA,  Skcondary.) 

SEPTICEMIA.  —  With  the  rarest  possible  exceptions,  true  septicaemia — 
septicaemia,  that  is,  confirmed  by  finding  bacteria  of  suppuration  in  the  blood — 
is  inevitably  fatal  within  a  few  days,  and  the  prognosis  is  really  the  diagnosis. 
Here  belong  those  cases  in  which  a  patient,  sometimes  a  nurse  or  doctor,  is 
taken  acutely  ill  with  what  appears  to  be  a  severe  type  of  influenza  :  where  there 
is  little  or  no  sign  of  inflammation  at  the  site  of  entry,  and  where  the  utter 
prostration,  high  fever,  septic  rashes,  diarrhoea,  or  onset  of  peritonitis  or  abscesses, 
leads  to  an  examination  of  the  blood.     It  is  always  a  very  grave  sign  when 


470 


INDEX     OF     PROGNOSIS 


effectual  treatment  of  the  primar\-  focus  of  a  suppuration  does  not  produce  marked 
improvement  within  two  days.  Occasionally  one  sees  cases  of  probable  septi- 
cemia in  which  antistreptococcus  serum  seems  to  work  like  a  charm. 

A.  Rendle  Short. 
SINUS    THROMBOSIS,    LATERAL,— (5ee   Intracranial   Complications   of 
Ear  Disease.) 

SMALL-POX. — The  prognosis  of  this  disease  must  be  considered  in  so  far  as 
it  is  influenced  by  the  following  factors  :  (i)  The  age,  (2)  Sex,  and  (3)  Race  of 
the  patient ;  (4)  Nature  of  the  attack  ;  (5)  Presence  of  special  symptoms  ;  (6) 
Occurrence  of  complications  ;  (7)  Character  of  the  epidemic  ;  and,  further,  by  the 
vejry  important  factor,  (8)  The  condition  of  the  patient  in  respect  of  vaccination. 

I .  Age. — Amongst  the  unvaccinated,  all  the  evidence  goes  to  show  that  small-pox 
is  very  fatal  to  the  young.  If  we  refer  to  times  in  which  the  disease  was  not 
controlled  by  vaccination,  we  find  that  amongst  the  total  number  of  deaths 
from  small-pox  at  all  ages,  the  proportion  amongst  children  under  five  was 
very  high.  Thus,  at  Geneva,  during  the  3-ears  1580  to  1760,  there  were  25,349 
deaths  from  small-pox  ;  83  per  cent  of  these  were  children  under  five  years 
of  age,  and  48  per  cent  were  under  two.  At  the  Hague,  for  fifteen  years,  the 
proportion  of  deaths  under  five  was  73-4  per  cent  ;  in  Sweden,  during  the  years 
1770  to  179S,  78-4  per  cent ;  in  Kilmarnock,  during  1728  to  1764,  90-5  per  cent  ; 
in  Chester,  in  1774,  89  per  cent ;  in  Manchester,  during  1768  to  1774,  95  per  cent  ; 
in  Warrington,  in  1773,  94  per  cent;  and  in  Edinburgh,  during  1764  to  1783, 
94  per  cent.^  There  are  no  records  which  are  extensive  or  accurate  enough  to 
furnish  a  definite  statement  as  to  the  fatality  at  the  different  ages  in  those  times  ; 
but  if  we  argue  from  what  has  taken  place  amongst  the  unvaccinated  during 
recent  years,  we  may  safely  assert  that  then,  as  more  recently,  the  fatahty 
amongst  young  children  was  high.  The  following  table  has  been  compiled  from 
the  annual  reports  of  the  Metropohtan  Asylums  Board  (London),  for  the  years 
1892  to  1895  and  1901  to  1903,  and  from  the  reports  on  small-pox  epidemics  in 
several  large  towns  in  England  (Leicester,  Gloucester,  Manchester,  Oldham, 
Chadderton,  and  Bradford)  during  the  period  from  1892  to  1896,  made  to  the 
Royal  Commission  on  Vaccination.  All  cases  doubtful  as  regards  vaccination 
are  excluded  from  these  figures. 

pATALITY   OF   SmALL-POX  AMONGST   THE    UNVACCINATED  ACCORDING   TO  AgE. 


Age 

Cases 

Deaths 

Fatality 

per  cent 

Under  5 

1510 

645 

ii-7 

5  to     9 

1253 

246 

19-6 

10  to  14 

663 

115 

17-3 

15  to  19 

393 

77 

19-5 

20  to  29 

447 

131 

29-2 

30  to  39 

152 

62 

40-7 

40  to  49 

73 

43 

58-9 

50  to  59 

26 

12 

46-2 

60  to  m 

15 

/ 

46-6 

70  and  over 

6 

2 

33-3 

Total  Cases 

4538 

1340 

29-5 

From  this  table  it  appears  that,  during  the  epidemics  from  which  the  figures 
are  derived,  the  fatahty  was  very  high  amongst  children  under  five,  that  it  fell 


SMALL-POX 


471 


considerably  during  the  next  two  quinquennial  periods,  and  then  quickly  rose 
again.  But  even  the  lowest  fatality,  17*3  per  cent  for  children  between  the 
ages  of  ten  and  fifteen  years,  is  high  ;  and  the  fatality  for  all  ages,  29"5  per  cent, 
is  very  high  compared  with  that  which  is  found  in  such  diseases  as  typhoid  fever 
and  scarlet  fever. 

Amongst  the  vaccinated,  however,  i.e.,  those  vaccinated  in  infancy,  the 
prognosis  is  very  different.  The  following  table  has  been  drawn  up  from  the 
same  reports  of  the  Metropohtan  Asylums  Board  as  were  employed  for  the 
preparation  of  the  table  given  above  relating  to  the  unvaccinated,  so  that  the 
two  tables  are  very  rightly  comparable. 

Fatality  of  Small-pox  amongst  the  Vaccinated,  according  to  Age. 


Age 

Cases 

Deaths 

Fatality 

per  cent 

Under  5 

39 

1 

2-5 

5  to    9 

285 

2 

0-7 

10  to  14 

870 

7 

0-8 

15  to  19 

1752 

30 

1-7 

20  to  29 

4648 

219 

4-7 

30  to  39 

3097 

335 

10-8 

40  to  49 

1571 

239 

15-2 

50  to  59 

552 

89 

16  T 

60  to  69 

221 

47 

21-2 

70  and  over 

66 

13 

19-5 

Total  Cases 

13101 

982 

7-4 

■  From  this  table  we  find  that,  amongst  the  vaccinated,  the  fatality-rate  is  under 
5  per  cent  for  persons  under  thirty.  It  is  especially  low  between  the  ages  of 
five  and  fifteen,  being  less  than  i  per  cent.  After  thirty,  the  fatality  rises,  and  it 
is  about  20  per  cent  amongst  those  over  sixty.  But  even  the  highest  fatalitj^- 
rates  amongst  the  vaccinated  are  only  a  trifle  higher  than  the  lowest  amongst 
the  unvaccinated.  And  it  may  be  concluded,  from  a  comparison  of  the  two  tables, 
that  while  infant  vaccination  affects  most  favourably  the  prognosis  at  all  ages, 
the  most  beneficial  effects  are  to  be  noticed  in  those  under  thirty  years  of  age, 
and  especially  in  children  between  the  ages  of  five  and  fifteen. 

Unmodified  confluent  small-pox  is  extremely  fatal  to  children  under  two  years 
of  age,  and  very  fatal  in  those  between  two  and  five. 

2.  Sex. — Most  authorities  state  that  sex  has  very  little  influence  on  the 
prognosis.  There  are,  however,  few  statistics  bearing  on  the  point  in  which  the 
vaccinated  are  distinguished  from  the  unvaccinated  cases.  During  the  years 
1892  to  1895,  534  unvaccinated  males  and  537  unvaccinated  females  were  treated 
in  the  small-pox  hospital  of  the  Metropolitan  Asylums  Board ;  90  males  and 
112  females  died,  so  that  the  fatality  amongst  the  former  was  i6-8  per  cent,  and 
amongst  the  latter  20-8  per  cent.  But  these  figures  are  too  small  to  warrant 
a  general  conclusion.  During  the  same  years,  and  at  the  same  hospital,  1883 
vaccinated  males  and  1365  vaccinated  females  were  treated  :  of  the  former, 
58,  or  3  per  cent,  died  ;  of  the  latter,  40,  or  2-9  per  cent  ;  so  that  in  these  cases 
the  fatality  was  the  same  in  each  sex.  Welch  and  Schamberg  state  that  in  certain 
epidemics  in  Philadelphia  the  fatality  amongst  4593  males  was  27-4  per  cent, 
and  amongst  2606  females  25-7  per  cent  ;  and  McCombie  puts  the  male  fatality 
at  I  per  cent  higher  than  the  female.  These  writers  are  referring  to  vaccinated 
and  unvaccinated  cases  taken  together. 


472  INDEX     OF     PROGNOSIS 

3.  Race. — It  has  been  stated  by  more  than  one  author  that  smaU-pox  is  much 
more  fatal  amongst  the  dark  races  of  mankind  than  amongst  the  white.  There 
is  historic  evidence  to  show  that  when  the  disease  has  been  introduced  into 
certain  countries  for  the  first  time  (as  into  Mexico  when  it  was  conquered  by  the 
Spaniards),  the  mortahty,  and  apparently  also  the  fatality,  has  been  very  high. 
The  statement  made  above  concerning  race  may  have  been  true,  to  a  certain  ex- 
tent, so  far  as  the  more  remote  past  is  concerned  ;  but  it  is  doubtful  whether  it  is 
true  at  the  present  day.  The  following  figures,  given  b}^  Welch  and  Schamberg, 
refer  to  unvaccinated  patients  treated  in  the  Philadelphia  Municipal  Hospital  : — 
Amongst  2036  whites  there  were  910  deaths,  a  fatahty  of  44-7  per  cent ;  while 
amongst  637  negroes  there  were  315  deaths,  a  fatahty  of  49-4  per  cent.  The 
figures  are  scanty  and  the  difference  in  the  fatality-rates  not  very  great.  But 
the  character  of  the  epidemic  is  of  great  importance.  Thus  the  writers  just 
quoted  state  that  during  the  years  1898,  1899,  and  1900  small-pox  of  an  extremely 
mild  type  prevailed  in  certain  parts  of  the  United  States,  and  that  they  treated 
in  hospital  162  patients  (of  whom  138  were  unvaccinated)  without  a  single  death  ; 
150  of  the  patients  were  negroes.  A  very  mild  forni  of  small-pox  (known  as 
Amaas)  has  also  been  prevalent  during  recent  years  amongst  the  Kaffirs  in  South 
Africa.  This  evidence,  therefore,  goes  to  show  that  race  has  very  httle  influence 
on  the  mortality. 

4.  The  Nature  of  the  Attack  is  of  great  importance.  I  have  added  together 
the  figures  presented  to  the  Royal  Commission  on  \'accination,  which  were 
obtained  from  various  authorities,  from  Marson  (1836  to  1851,  at  the  Highgate 
Hospital)  to  Coupland  (1896,  in  the  Gloucester  epidemic). 

Amongst  the  unvaccinated,  I  find  that  of  478  malignant  or  haemorrhagic  cases, 
451  died,  a  fatahty  of  94-3  per  cent ;  of  5258  confluent  cases,  2393  died,  or 
43-8  per  cent ;  and  of  1068  discrete  (including  those  classed  by  Coupland  as 
coherent)  cases,  57  died,  or  5-3  per  cent.  It  will  thus  be  seen  that  nearly  all  the 
haemorrhagic  cases  are  fatal.  In  respect  of  the  confluent  and  discrete  cases,  the 
age  of  the  patient  must  be  taken  in  conjunction  with  the  character  of  the  attack 
(see  table  given  above)  ;  most  of  the  deaths  in  discrete  small-pox  occur  amongst 
children  under  three  years  of  age. 

Amongst  the  vaccinated  I  find,  from  the  figures  given  by  the  observers  just 
quoted,  that  of  529  mahgnant  cases,  425  were  fatal,  or  80-3  per  cent  ;  of  5394 
confluent  cases,  963  died,  or  17-8  per  cent ;  while  of  9603  discrete  cases,  42  died, 
or  0-4  per  cent.  It  will  be  observed  that  in  both  the  vaccinated  and  the  un- 
vaccinated the  prognosis  in  the  case  of  mahgnant  small-pox  is  very  grave.  In 
confluent  small-pox  the  prognosis  is  grave  in  the  unvaccinated,  much  less  so  in 
the  vaccinated.  In  all  forms  the  prognosis  is  much  more  favourable  in  the 
vaccinated  than  the  unvaccinated. 

Generally  it  may  be  stated  that  the  more  profuse  the  eruption  of  pocks,  the 
graver  is  the  prognosis. 

5.  Special  Symptoms. — If  the  symptoms  of  the  prodromal  or  initial  period 
be  mild,  then  the  attack  (eruptive  stage)  will  be  mild.  But  if  the  initial  sjmi- 
ptoms  be  severe,  the  eruptive  stage  wiU  not  necessarily  be  severe.  Often  it  will  be  ; 
often,  also,  it  will  not.  Even  an  attack  which  proves  to  be  very  much  modified 
is  occasionally  ushered  in  by  severe  initial  symptoms. 

Rashes. — Of  the  initial  rashes,  the  scarlatiniform  and  morbilhform  erythemas, 
whether  generalized  or  local,  are  usually  favourable,  especial!}^  when  the  patient 
is  vaccinated.  The  same  remark  is  true  of  the  pale  sepia  erythema  described  by 
Thomson  and  Brownlee  under  the  designation  '  capnitoid.'  The  generalized 
livid  (dark  plum-coloured)  erythema  is  of  very  bad  omen  ;  so  also  are  the 
erysipelatoid  (astacoid)  erythemas,  local  or  generalized. 


SMALL-POX  473 


The  haemorrhagic  initial  or  prodromal  rashes  are,  on  the  whole,  very- 
unfavourable.  When  the  hsemorrhages  are  small  (petechial),  not  very  numerous, 
and  of  a  bright  red  colour,  the  prognosis  is  not  so  grave  as  when  they  are  small, 
very  numerous,  and  of  a  purple  hue.  The  vaccinated  person  has  the  best  chance. 
The  occurrence  of  scattered,  purple,  blue-black,  or  inky  cutaneous  and  sub- 
cutaneous haemorrhages  is  very  ominous.  In  the  very  worst  cases  there  is  also 
an  erysipelatoid  erythema.  The  presence  of  haematuria,  metrorrhagia,  or  bleeding 
from  other  mucous  surfaces  aggravates  the  prognosis. 

The  symptoms  last  mentioned  are  amongst  those  which  are  to  be  observed  in 
malignant  or  haemorrhagic  small-pox,  which,  as  we  have  seen,  is  an  extremely 
fatal  form  of  the  disease.  Death  may  take  place  on  the  third  to  sixth  day, 
before  the  eruption  of  pocks  has  made  its  appearance.  Not  only  the  haemor- 
rhagic but  the  erysipelatoid  initial  rashes  are  prone  to  occur  in  malignant  small- 
pox. The  lumbar  pain  is  often  unusually  severe.  There  is  some  hope  of 
recovery  in  that  form  of  haemorrhagic  small-pox  in  which  the  haemorrhages  are 
limited  to  the  skin  immediately  beneath  and  around  the  pocks. 

Pocks. — It  has  already  been  stated  in  regard  to  the  eruption  of  pocks,  that 
the  more  profuse  it  is,  the  graver  is  the  prognosis.  The  outlook  is  especially 
bad  when  the  eruption  is  already  confluent  in  the  papular  stage  ;  then  the 
papules  are  often  softer  and  less  prominent  than  usual.  In  the  vesicular  and 
pustular  stages,  it  is  an  unfavourable  sign  if  the  pocks  are  whitish,  fiat,  and 
collapsed,  and  if  there  is  little  or  no  swelling  of  the  skin.  It  is,  on  the  other  hand, 
a  favourable  sign  if  the  pocks,  even  though  very  numerous,  run  through  the 
stages  of  vesiculation  and  pustulation  to  incrustation  more  quickly  than  usual  ; 
if  the  pocks  are  superficial  ;  if  they  are  small  or  of  variable  size  ;  and  lastly,  if, 
whether  in  the  vesicular  or  pustular  stage,  they  are  ill-developed.  These  modi- 
fications of  the  cutaneous  lesions  are,  at  the  present  time,  most  often  due  to 
previous  vaccination. 

If  there  are  many  pocks  on  the  mucous  membranes  of  the  mouth,  palate, 
pharynx,  and  especially  larynx  (as  shown  by  signs  of  laryngeal  obstruction), 
the  gravity  of  the  prognosis  is  much  augmented. 

In  haemorrhagic  small-pox  the  fatal  event  often  takes  place  on  the  third  to 
sixth  day  ;  in  confluent,  and  severe  discrete  cases,  the  dangerous  period  is  that 
of  the  suppuration  of  the  pocks,  that  is,  from  the  sixth  to  twelfth  day  of  the 
eruption  (eighth  to  fourteenth  of  the  illness).  Complications  are  very  likely 
to  set  in  during  this  stage. 

Other  Symptoms. — Marked  restlessness,  insomnia  and  delirium,  convulsions, 
coma,  prostration,  profuse  diarrhoea,  and,  in  children,  grinding  of  the  teeth,  are 
all  unfavourable  symptoms. 

6.  Complications. — These  are  especially  to  be  expected  in  the  most  severe  cases, 
either  during,  or  soon  after,  the  period  of  suppuration  of  the  pocks.  Those  which 
are  both  frequent  and  serious  are  oedema  of  the  lungs,  acute  bronchitis,  lobular 
pneumonia,  acute  dermatitis  and  cellulitis  with  suppuration,  erysipelas,  septi- 
caemia, and  pyaemia.  More  serious,  but  infrequent,  are  lobar  pneumonia, 
empyema,  gangrene  of  the  skin  (especially  of  the  scrotum),  arthritis,  and  acute 
myelitis.  Ocular  complications  are  common,  especially  after  confluent  and 
severe  discrete  attacks.  Extreme  inflammation  and  swelling  of  the  lids  is 
serious  because  it  leads  to  conjunctivitis,  corneitis,  corneal  ulcer,  and  panophthal- 
mitis, so  that  if  the  patient  survives  the  attack  of  small-pox,  his  sight  may  be 
lost  or  impaired  ;  but  conjunctivitis  and  corneitis  may  occur  independently  of 
oedema  of  the  eyelids.     Otitis  media  is  met  with  chiefly  in  children. 

Influence  of  Pregnancy. — In  Welch  and  Schamberg's  book  on  Acute  Con- 
tagious Diseases,  a  table  is  given  in  which  are  shown  details  of  113  cases  of 


474  INDEX     OF     PROGNOSIS 

small-pox  in  pregnant  women.  From  this  table  it  appears  that  in  67  of  the  113 
cases,  or  59  per  cent,  abortion  or  premature  delivery  took  place  ;  7  of  the  patients, 
or  6  per  cent,  died  undelivered  ;  20,  or  18  per  cent,  recovered  and  went  to 
delivery  at  full  term  ;  and  19,  or  17  per  cent,  left  the  hospital  still  carrying  the 
foetus,  and  no  further  information  was  to  be  obtained  concerning  them. 

In  73  cases  in  which  the  woman  was  attacked  by  small-pox  before  the  com- 
pletion of  the  seventh  month  of  pregnancy,  41  aborted,  or  56  per  cent  ;  while 
of  39  attacked  after  the  seventh  month,  25  were  delivered  prematurely,  or  64 
per  cent. 

The  fatality  was  much  higher  in  those  who  were  prematurely  delivered  than  in 
those  who  were  not ;  of  the  67  in  the  former  class,  28  died,  or  41-7  per  cent ;  while 
of  the  46  in  the  latter,  7  died,  or  15-2  per  cent. 

Miscarriage  takes  place  most  frequently  during  the  eruptive  stage  ;  but  the 
earlier  in  the  attack  it  occurs,  the  more  likely  is  the  event  to  prove  fatal.  The 
more  severe  the  attack,  the  greater  the  risk  of  premature  delivery  and  death. 
Vaccination  has  a  great  influence  in  prognosis.  Of  the  cases  quoted,  27  had  not 
been  vaccinated  and  20  of  them  died,  a  fatality  of  74  per  cent  ;  of  85  cases  in 
which  vaccination  had  been  performed  "  at  some  previous  remote  period," 
14  died,  a  fatality  of  16  per  cent. 

The  writers  point  out  that  the  death-rate  of  small-pox  in  pregnant  women 
varied  in  different  epidemics  ;  in  their  series,  in  three  different  epidemics,  it  varied 
from  13  to  51  per  cent.  The  miscarriage-rate  varied  less  widely,  from  55  to  61 
per  cent.  In  the  very  mild  epidemic  which  prevailed  in  Trinidad  during  1902 
to  1904,  Seheult  found  that  27  out  of  89  women  miscarried,  or  30  per  cent ;  none 
died. 

On  the  whole  it  may  be  concluded  that  an  attack  of  small-pox  is  a  most  serious 
event  for  a  pregnant  woman  ;  and  that  the  vaccinal  condition  of  the  patient  and 
the  nature  of  the  attack  are  of  prime  importance  in  determining  the  issue. 

In  respect  of  the  child,  the  earlier  in  gestation  the  mother  is  attacked  by 
small-pox,  the  more  likely  is  the  child  to  perish.  In  the  later  months,  the  child 
may  be  born  with  the  eruption  of  small-pox  out  upon  it,  or,  if  it  live,  it  may 
develop  the  rash  later.  A  living  child  born  of  a  variolous  mother  may  not  have 
small-pox  at  once,  and  yet  is  rarely  immune  to  vaccination. 

7.  Character  of  the  Epidemic. — Allusion  has  already  been  made  to  this  factor 
when  the  question  of  the  influence  of  race  M'as  under  consideration.  One 
epidemic  will  differ  very  widely  from  another  in  respect  of  its  case-mortality, 
that  is  to  say,  of  the  virulence  of  the  immediate  cause  of  the  disease,  whatever 
it  may  be.  The  fatality  of  the  London  epideraic  of  1902  was  i6'8  per  cent,  and 
of  that  of  1903,  3 '4  per  cent.  The  recent  epidemic  in  Sydney  has  been 
characterized  by  extraordinary  mildness.  According  to  the  statement  of  J.  H. 
Jones, ^  there  were  1000  cases  with  but  i  death.  Even  young  children  had 
the  disease  in  a  mitigated  form.  Apparently  most  of  the  cases  occurred  in 
unvaccinated  persons.  This  outbreak  was  also  characterized  by  its  low  power 
of  infectivity. 

8.  Vaccination. — One  or  two  more  points  require  to  be  dealt  with  under  this 
heading  which  have  not  been  touched  upon  in  the  previous  paragraphs.  It  will  be 
seen  from  the  table,  given  above,  of  the  fatality  of  small-pox  in  the  unvaccinated, 
that  on  the  whole  it  increases  with  age,  that  is,  with  the  lengthening  of  the 
interval  between  vaccination  in  infancy  and  the  attack  of  small-pox.  We  must 
now  consider  the  question  of  the  expectation  of  an  attack  of  small-pox  in  those 
who  have  been  vaccinated  in  infancy,  when  they  are  exposed  to  the  infection 
of  the  disease.  Very  careful  investigation  into  this  point  was  made  in  the 
epidemics  at  Sheffield,  Warrington,  Dewsbury,  Leicester,  and  Gloucester,  and  the 


SPINA     BIFIDA 


475 


results  were  reported  to  the  Royal  Commission  on  Vaccination.  The  inhabitants 
of  houses  invaded  by  small-pox  in  those  epidemics  were  divided  into  two  classes, 
the  unvaccinated  and  the  vaccinated.  The  number  of  persons  in  each  class 
was  enumerated,  and  also  the  number  in  each  who  were  attacked  by  small-pox. 
A  further  separation  was  made  of  these  persons  into  two  groups,  those  under  ten 
years  of  age,  and  those  of  ten  years  old  and  over.  Adding  the  totals  from  the 
five  towns  together  we  get  the  following  figures  : — 

Proportion  of  Unvaccinated  and  Vaccinated  Persons  exposed   to 
Attack  who  were  Attacked. 


Under  ten 

Over  ten 

Condition 

Number  ol 
Persons 

Number 
attacked 

Percentage 

Number  of 
Persons 

Number 
attacked 

Percentafe 

Unvaccinated 
Vaccinated  - 

2317 
5810 

1133 
449 

48-8 

77 

1195 

20822 

631 

5997 

52-8 
29-0 

It  will  be  noticed  that  the  attack- rate  in  the  unvaccinated  is  not  very  different 
in  those  under  or  over  ten.  In  the  vaccinated,  however,  the  attack -rate  is  four 
times  higher  in  those  over,  than  in  those  under,  ten.  These  figures  deal  almost 
entirely  with  persons  vaccinated  in  infancy.  The  protective  power  of  vaccination 
wanes  as  the  length  of  time  from  the  vaccination  increases.  But  even  after  its 
power  of  preventing  an  attack  of  small-pox  has  gone,  its  influence  in  modifying 
the  attack  remains  for  a  considerable  time.  It  may  also  be  stated  that  the 
incidence  of  the  severe  forms  of  small-pox  is  much  less  amongst  the  vaccinated 
than  the  unvaccinated.  The  prognosis  is  also  affected  by  the  ejficiency  of  the 
vaccination,  as  measured  by  the  number  and  character  of  the  vaccination  scars. 
The  larger  the  total  area  of  the  vaccination  marks,  the  better  the  prognosis. 

Re-vaccination  will  restore  to  the  already  vaccinated  individual  any  loss  of  the 
immunity  conferred  by  the  primary  vaccination.  It  is  rare  to  meet  with  attacks 
of  small-pox,  and  still  m.ore  rare  to  meet  with  fatal  cases,  in  persons  who  have 
been  successfully  re-vaccinated. 

References. —  ^Dr.  J.  C.  McVail's  evidence  before  the  Royal  Commission  on 
Vaccination  ;    '^Guy's  Hosp.  Gaz.  1914,  xxviii,  95.  £_   py,  Goodall. 


SPINA  BIFIDA. — We  shall  have  to  consider:  (i)  The  prospects  of  survival 
apart  from  treatment ;  (2)  The  results  of  injection  methods  ;  and  (3)  The  prognosis 
after  operation. 

I.  Survival  apart  from  Treatment. — It  is  quite  certain  that  the  patient  may, 
in  rare  cases,  survive  and  grow  up.  The  report  of  the  Clinical  Society,^  many 
years  ago,  was  able  to  present  about  a  dozen  such  cases,  several  of  whom  were  over 
twenty,  and  two  over  forty,  years  of  age  ;  one  or  two  had  obtained  a  spontaneous 
cure  by  shrinkage.  Nevertheless,  this  happy  event  must  be  regarded  as  very 
exceptional.  In  1882,  of  649  cases  of  spina  bifida  dying  in  England,  612  were  in 
their  first  year,  and  a  great  number  of  these  died  within  the  earlier  months. 
Morton  estimated  that  only  i  per  cent  grow  up  without  treatment  ;  this  is 
probably  too  low  a  figure.  Of  90  cases  not  operated  on,  20  lived  to  the  age  of 
five. 

The  causes  of  death  are  rupture,  leading  to  fatal  drainage  of  fluid  ;  meningitis ; 
and  hydrocephalus.  The  children  who  survive  frequently  suffer  from  cystitis, 
and  may  be  paralyzed  in  their  legs. 


476  INDEX     OF     PROGNOSIS 

The  only  cases  in  which  there  is  a  reasonable  prospect  of  survival  are  those  of 
meningocele  with  a  thick  skin  covering. 

2.  Results  of  Injection  of  Morton's  Fluid. — On  paper,  this  is  by  far  the  best 
method  of  treatment.  According  to  the  report  of  the  Clinical  Society,  of  71 
cases,  35  were  cured,  27  died,  5  were  improved,  and  5  not  improved.  Morton^ 
himself  had  29  patients,  of  whom  only  6  died.  But  a  closer  examination 
presents  the  picture  in  a  very  different  aspect.  The  operative  procedure 
is,  of  course,  by  no  means  so  dangerous  as  an  excision,  and  therefore  those 
dying  ^vithin  a  month  are  fewer  ;  but  the  great  majority  of  the  71  cases 
given  in  Morton's  book  have  only  been  followed  for  a  very  short  time  ;  and  when 
the  book  appeared,  24  of  those  whose  history  had  been  followed  up  were  known 
to  be  dead.  The  cure  was  often  partial ;  many  tappings  and  injections  were 
necessary  in  several  instances,  and  occasionally  there  was  no  improvement  even 
after  this.  It  is  therefore  quite  impossible,  from  such  evidence,  to  obtain  figures 
sufficiently  reliable  to  compare  udth  those  obtained  by  operation.  One  can  only 
say,  in  general  terms,  that  the  procedure  itself  is  not  very  dangerous,  even  in 
young  infants  ;  that,  if  repeated,  it  usually  causes  some  shrinkage  of  the  sac  ; 
but  that  a  great  number  eventually  succumb  to  intercurrent  ailments.  At  the 
Children's  Hospital,  Manchester,  of  12  cases,  3  were  cured,  8  died,  and  i  was  not 
improved. 

Probably  modern  surgery  has  gone  too  far  in  abandoning  the  injection  of 
Morton's  fluid  so  completely  as  it  has  done. 

3.  Prognosis  after  Operation. — It  is  extremely  difficult  to  obtain  figures  which 
are  really  comparable,  because  of  the  variations  in  the  age  at  which  the  operation 
is  performed.  If  the  surgeon  waits  until  an  age  when  the  weakly  children  will 
have  died  off,  good  figures  can  be  obtained  ;  if  he  operates  in  early  infancy,  in 
hopes  of  saving  a  few  who  would  otherwise  die,  there  will  be  a  heavy  mortality. 
A  number  of  the  children  succumb  in  the  next  few  months,  even  after  operation. 

Nicoll,^  of  Glasgow,  reports  the  results  of  excision  in  32  cases,  mostly  young 
infants,  treated  by  himself ;  but  unfortunately  they  were  not  usually  followed 
up  more  than  a  month  or  two;    of  these,  7  died  within  a  month,  or  21-8  per  cent. 

Sachtleben,*  in  T903,  recorded  18  operations  in  Mikulicz's  clinic  :  Of  these, 
6  died  soon  after  operation  ;  of  12  recoveries,  6  died  within  a  year.  Only 
6,  therefore,  were  alive  a  year  after  ;  5  of  these  were  completely  cured,  all 
being,  in  the  first  place,  meningoceles. 

Moore,  °  in  1905,  made  a  study  of  all  the  cases  treated  by  operation  mentioned 
in  the  Surgeon-General's  Index  Catalogue  for  nearly  a  century.  He  estimates 
that  the  mortality  at  the  present  time,  amongst  children  with  spina  bifida  operated 
on  in  infancy,  is  about  35  per  cent,  and  that  not  more  than  half  the  total  num- 
ber are  alive  at  ths  end  of  a  year.  If  operation  is  postponed  until  they  are 
five  years  old  or  over,  the  mortality  is  only  4-7  per  cent.  Even  after  operation 
infants  may  develop  hydrocephalus,  paraplegia,  or  incontinence  ;  and  if  these 
conditions  were  already  present,  it  is  very  unlikely  that  they  will  be  improved. 

Boettcher  reports  a  series  of  39  cases  operated  on  by  himself  ;  13  died,  and  of 
the  26  survivors  12  died  within  a  few  months,  and  14  (that  is,  36  per  cent  of  the 
whole)  were  cured.     These  were  all  meningoceles. 

At  the  Manchester  Children's  Hospital,^  out  of  8  cases  treated  by  operation, 
5  recovered  and  3  died.     The  age  is  not  stated. 

At  two  Bristol  hospitals,  10  infants  have  been  operated  on  :  6  died,  five  of  the 
deaths  occurring  within  a  few  days  ;  i  has  been  lost  sight  of  ;  3  are  alive, 
respectively  three,  five,  and  eight  years  after  the  operation.  Of  these  three,  one 
is  quite  well,  another  has  incontinence,  and  the  third  has  paralysis  of  the  legs 
dating  from  the  operation.     Of  7  children  not  operated  on,  6  died  within  a  few 


SPINAL-   CARIES  47^ 


months,  and  i,  aged  three  years,  is  still  alive,  paralyzed,  hydrocephaUc,  herniated, 
and  always  ailing. 

Summary. — We  may  conclude,  therefore,  on  the  rather  unsatisfactory  evidence 
at  present  available  : — 

1.  That  survival  is  quite  exceptional,  apart  from  treatment ;  and  a  surviving 
child  will  often  be  paralyzed  and  suffer  from  incontinence  of  urine  or  hydro- 
cephalus. 

2.  That  injection  of  Morton's  fluid  is  comparatively  safe  at  the  time  ;  but 
probably  half  the  cases  die  within  a  few  months,  and  in  about  one  in  seven  the 
spina  bifida  is  not  cured. 

3.  That  operation  in  early  infancy  has  an  immediate  mortality  of  35  per  cent, 
and  less  than  half  the  cases  grow  up  ;  it  cures  the  spina  bifida,  but  will  not 
improve  any  paralysis,  incontinence,  or  hydrocephalus.  In  older  children,  over 
five,  the  mortality  is  low  (about  5  per  cent)  and  the  prospect  of  cure  excellent. 

Cases  of  meningocele  with  a  thick  covering  are  favourable  ;  syringomyelocele 
and  meningomyelocele,  especially  with  a  thin  covering,  usually  threaten  early 
death,  which  is  scarcely  a  calamity  in  view  of  the  probability  of  helplessness  and 
feeble  intelligence  in  the  child  if  it  survive. 

References. — ^Trans.  Clin.  Soc.  Land,  xviii,  339  ;  ^viorton,  Spina  Bifida,  1887  ; 
^Nicoll,  Brit.  Med.  Jour.  1898,  ii,  1142  ;  *Sachtleben,  Centr.  /.  Chir.  1904,  341  ;  ^Moore, 
Trans.  Amer.  Surg.  Assoc.  1905;  ^Thorburn,  "Spina  Bifida,"  Burghara's  System  of 
operative  Surgery.  _4_  ^^„^;^  5;^^^^_ 

SPINAL  CARIES. — The  following  points  demand  attention  in  attempting 
to  forecast  the  prognosis  for  patients  with  tuberculous  disease  of  the  spine  : — ■ 
(i)  The  prognosis  as  to  life  ;  (2)  The  prospects  of  cure  in  ordinary  cases,  and 
length  of  time  likely  to  be  necessary;  (3)  The  prognosis  when  paraplegia  is 
present,  and  the  value  of  laminectomy  ;  (4)  The  prognosis  when  the  disease  is 
complicated  by  abscess  formation,  and  notably  by  psoas  abscess.  This  is  dealt 
with  elsewhere  {see  Psoas  Abscess). 

1.  Prognosis  as  to  Life. — Undoubtedly  patients  with  spinal  caries  run 
some  risk  of  early  death.  According  to  some  old  authorities  quoted  by  Tubby, 
about  a  third  of  the  cases  die  within  a  few  years  of  the  onset.  Nowadays  it  is 
quite  certain  that  with  anything  like  favourable  circumstances  and  proper 
treatment  the  danger  to  life  is  much  less  than  this.  In  1903  Goldthwait  published 
a  study  of  the  end-results  of  62  cases  treated  in  a  Boston  hospital  and  followed 
up  till  eight  years  afterwards,  and  including  20  with  abscesses  and  11  with 
paraplegia,  only  11  dying  (including  8  abscess  cases  and  2  paraplegics).  Tubby 
followed  99  cases  for  two  and  a  half  years  ;  of  these,  12  died.  Patients  seen  in 
private  practice,  or  able  to  be  treated  at  an  open-air  hospital  such  as  Alton,  do 
better  still,  and  the  true  mortality  is  probably  between  5  and  10  per  cent.  It 
must  be  admitted,  however,  that  the  patients  are  usually  delicate  all  their  days, 
and  not  likely  to  reach  a  great  age. 

Menaces  to  life  are — infected  abscesses,  paraplegia  leading  to  sphincter  troubles, 
pulmonary  tuberculosis,  and  of  course  any  evidence  of  commencing  tuberculous 
meningitis,  such  as  mental  change,  incessant  vomiting,  headache,  or  unexplained 
continued  fever.  In  cases  where  there  is  great  angular  curvature  a  good 
many  die  of  cardiac  lesions.  In  cervical  caries  there  is  some  danger  of 
sudden  death  by  displacement. 

2.  The  Prospects  of  Cure  in  Ordinary  Cases. — Given  favourable  circumstances, 
country  air,  and  good  treatment,  the  great  majority  of  the  patients  make  an 
excellent  recovery,  and  may  indeed  become  hale  and  hearty,  though  there  is 
likely  to  be  some  permanent  deformity.     If  the  treatment  was  instituted  earl}-. 


478 


INDEX     OF     PROGNOSIS 


this  deformity  will  not  usually  be  severe  ;  any  curvature  already  present  at  the 
commencement  of  treatment  will  probably  be  permanent,  but  it  need  not 
increase.  According  to  Marsh  and  Watson,  from  80  to  90  per  cent  of  cases 
treated  in  private  practice  or  at  Alton,  and  taken  early  in  the  pre-curvature 
stage,  recover  completely.  The  treatment  will  last  about  two  years,  and 
supervision  must  be  exercised  for  still  another  year. 

The  outlook  is  not  always  so  encouraging.  Social  position  makes  a  great  deal 
of  difference  ;  in  towns  the  children  of  the  poor  do  badly.  Young  children  are 
more  likely  to  suffer  severely  or  to  die  than  adults.  Pregnancy  as  a  rule  makes 
matters  much  worse.  A  long  length  of  spine  affected  makes  a  bad  prognosis. 
Situation  in  the  dorsal  spine  is  less  favourable  than  in  the  lumbar. 

Some  years  ago  Tubby  and  Jones  pubUshed  statistics  to  show  the  effect  of 
forcible  straightening  of  the  curvature  at  one  sitting  ;  although  they  have  now 
abandoned  the  method,  it  enables  one  to  obtain  some  insight  into  the  ordinary 
prognosis  in  spinal  caries.  Of  99  cases  followed  two  and  a  half  years  :  44 
recovered  sufficiently  to  be  able  to  walk,  the  curvature  being  improved  or  cured  ; 
28  were  still  recumbent ;  12  died  ;  15  were  lost  sight  of.  Further  details  are 
furnished  :  it  is  stated  that  16  were  no  better  ;  17  developed  abscess  ;  18  were,  or 
became,  paraplegic — of  these,  12  recovered  and  6  were  still  afflicted.  It  is 
declared  that  these  figures  compare  well  with  those  obtained  by  the  usual 
conservative  nieans. 

Recrudescence  in  middle  life  is  not  very  rare,  but  usually  ends  in  recovery. 

3.  Prognosis  in  Paraplegic  Cases. — All  experienced  observers  agree  that 
cases  of  paraplegia  treated  by  prolonged  rest  and  weight-extension,  preferably 
in  the  open  air,  usually  recover  the  power  of  walking,  but  this  result  may  not 
be  obtained  for  six,  or  even  twelve,  months.  Probably  about  80  per  cent  of  the 
patients  can  be  improved,  if  not  cured,  by  this  means. 

There  is  a  certain  residuum  in  whom  conservative  measures  do  not  appear 
to  do  any  good,  and  where  laminectomy  may  be  indicated.  It  ought  not  to  be 
resorted  to  until  after  long  trial  of  the  means  already  mentioned.  Many  years 
ago  a  few  brilliant  cures  reported  by  Macewen  and  Horsley  led  the  profession 
to  overrate  the  value  of  operation  in  these  cases. 

Lloyd,  in  1902,  pubUshed  an  account  of  128  cases — abstracted  from  the  htera- 
ture,  and  therefore  possibly  unduly  favourable.  They  are  not  so  good,  however, 
as  Thorburn's  results,  drawn  from  his  own  personal  cases.  It  will  be  observed 
that  the  mortality,  immediate  and  remote,  is  about  44  per  cent  in  Lloyd's  series, 
but  less  than  20  per  cent  in  Thorburn's.  Those  cured  amount  to  about  one- 
quarter  of  the  whole  ;  with  those  improved,  the  proportion  is  brought  up  to 
one-third.  It  must  be  remembered  that  Thorburn  and  most  other  surgeons  only 
operate  on  bad  cases,  after  six  months'  rest  has  failed. 

End-results  of  Laminectomy  for  Paraplegia  in  Spinal  Caries. 


Operator 

Cases 

Died  ol 
operation 

Died  later 

Cured 

Improved 

Kelieved 

but 
recurred 

Not 
improved 

Thorburn   - 

17 

2 

1 

4 

0 

5 

3 

Lloyd 

128 

21 

(or  16'5 
per  cent) 

36 

(or  28 
cent) 

37 

(or  -28 
per  cent) 

16 

(or  12'S 
per  cent) 

18 

(or  14 
per  cent) 

SPINE.     INJURIES     OF  479 

4.  Prognosis  when  Psoas  Abscess  is  Present. — As  stated  elsewhere  {see  Psoas 
Abscess),  cases  of  psoas  abscess  recover,  die,  or  become  chronic  invalids  in  about 
equal  proportions. 

Summary. — We  may  take  it  that  good  social  position  and  proper  treatment 
commenced  early  are  very  important  ;  that  the  mortality  is  about  5  to  10  per 
cent ;  that  in  early,  well-treated  cases  in  favourable  surroundings  about  80  to 
90  per  cent  recover  ;  but  that  taking  the  average  of  all  cases,  it  is  probably  only 
about  half  that  do  so  ;  that,  of  paraplegic  cases,  three  out  of  four  recover  with 
prolonged  rest  and  extension,  but  if  this  fails,  laminectomy  will  reheve  or  cure 
about  a  third  of  those  operated  on — the  mortality  of  this  operation,  immediate 
and  remote,  may  be  40  per  cent. 

References. — Tubbj',  Deformities,  including  Diseases  of  Bones  and  Joints,  vol.  ii., 
1012  ;  Thorburn,  "  Spinal  Cord."  Burghard's  System  of  Operative  Surgery  ;  Lloyd, 
PhHadelph.  Med.  Ann.  1902,  Feb. ;  Marsh  and  Watson,  Diseases  of  the  Joints  and 
Spine.  1910.  A     Rendle  Short. 

SPINE,    INJURIES    OF. — We   shall  consider   the  prognosis  after  injuries  of 

the  spine  under  the  following  headings  :  (i)  No  evidence  of  fracture,  dislocation, 
or  gross  injury  of  the  spinal  cord  ;  (2)  Fractured  or  dislocated  spine,  with  or  with- 
out involvement  of  the  cord,  apart  from  operative  treatment  ;  (3)  The  value  of 
operative  treatment  ;    (4)   Gunshot  and  other  wounds  of  the  spine. 

I.  Cases  without  Evidence  of  Fracture,  Dislocation,  or  Gross  Injury  of  the 
Spinal  Cord. — It  is  notoriously  difficult  to  arrive  at  an  accurate  diagnosis  and 
prognosis  in  this  class  of  injuries,  and  much  litigation  and  cross-swearing  of 
medical  witnesses  is  the  consequence.  "  Say  it's  your  back.  Bill ;  the  doctors 
can't  never  get  round  your  back  "  ;  so  runs  the  classical  advice  given  by  a  work- 
man to  his  injured  mate. 

In  the  great  majority  of  cases,  sprains,  wrenches,  or  contusions  of  the  spine, 
without  evidence  of  bone  or  nerve  injury,  improve  quickly,  and  the  patient 
is  well  in  a  month  or  two.  There  are,  however,  three  groups  of  symptoms  which 
make  the  outlook  much  less  favourable. 

First,  we  have  to  consider  the  possibility  of  the  onset  of  tuberculosis.  Un- 
doubtedly this  is  a  very  rare  sequel  ;  if  a  hundred  cases  of  spinal  injury  were 
followed  up,  it  is  not  likely  that  any  would  show  it  ;  but,  on  the  other  hand, 
patients  with  caries  of  the  spine  do  often  date  it  from  an  injury.  The  best 
evidence  of  the  onset  of  tuberculosis  following  a  trauma  will  be  abscess  forma- 
tion, angular  curvature,  or  skiagraphic  evidence  of  excavation  of  the  bones.  I 
have  under  my  care  at  present  two  patients  with  severe  pain  in  the  back  and 
marked  angular  deformity  following  upon  heavy  falls  which  laid  them  up  in 
bed  for  several  weeks.  The  angulation  came  on  gradually  in  the  course  of  the 
next  year  or  two.  Some  of  these  cases  are  apparently  due  to  a  traumatic  osteitis 
and  not  tubercle,  and  recover  after  prolonged  rest  in  bed. 

Second,  it  is  quite  common  for  patients,  especially  workmen  seeking  compen- 
sation, to  complain  of  persistent  stiffness  and  pain  in  the  back,  often  with  a 
tender  spot,  for  months  or  years  after  the  accident,  and  the  physical  examination 
may  reveal  nothing  at  all.  It  is  usually  a  matter  of  the  greatest  difficulty  to 
make  a  proper  distinction  between  fraud,  subconscious  exaggeration,  fear  of 
being  hurt,  and  genuine  pain  due  to  adhesions,  in  these  cases.  Sometimes  it  is 
rather  by  detective  than  medical  methods  that  a  correct  opinion  is  arrived  at,  as 
for  instance  by  noticing  how  readily  the  patient  can  stoop  to  pick  up  anything 
when  he  thinks  that  he  is  not  being  observed.  Sometimes  a  cure  may  be  obtained 
by  forcible  flexion  under  an  anaesthetic,  followed  by  movements  and  massage. 
In  many  cases  recovery  is  rapid  when  a  financial  settlement  has  been  arrived  at 
and  the  patient  has  a  strong  motive  to  get  well. 


480  INDEX     OF    PROGNOSIS 

Third,  we  have  to  take  into  account  the  condition  called  iraumaiic  neuras- 
thenia or  hysteria,  '  concussion  '  of  the  spine,  or  '  railway  spine,'  with  its  protean 
manifestations.  This  is  something  more  than  the  persistent  pain  and  stiffness 
just  described  ;  that  is  usually  a  well-marked  feature,  but  in  addition  there 
may  be  a  condition  of  extreme  nervous  prostration,  coming  on  a  few  days  or 
weeks  after  the  accident,  not  usually  at  once.  Sleep  is  bad,  and  the  patient  is 
very  feeble,  and  lives  in  terror  of  paralysis.     This  is  traumatic  neurasthenia. 

Less  commonly,  one  finds  a  remarkable  simulation  of  organic  disease.  There 
may  be  areas  of  complete  anaesthesia,  having  the  sock  or  stocking  distribution, 
and  perhaps  extreme  hyperesthesia  just  above  the  insensitive  region.  Paralysis, 
with  exaggeration  of  knee-jerks,  may  be  present,  and  sometimes  retention  of 
urine.     This  is  traumatic  hysteria. 

The  real  difficulty  is  introduced  into  these  cases  by  the  fact  that  there  are  a 
few  cases  on  record  of  genuine  nervous  lesions  apparently  due  to  an  injury  to 
the  back,  but  coming  on  very  slowly  afterwards,  persisting  throughout  life,  or 
ending  fatally.  Several  examples  are  quoted  in  the  third  edition  of  Osier's 
Principles  and  Practice  of  Medicine.  The  following  case  came  under  the 
writer's  notice.  A  gentleman  fell  from  a  horse  and  sustained  a  blow  on  the 
back  (not  head).  For  several  weeks  he  was  apparently  fairly  well,  though  a 
good  deal  shaken  and  neurasthenic  ;  then  gradually-increasing  weakness  of 
the  legs  came  on,  and  after  some  months  he  became  unconscious  and  died. 
The  autopsy  showed  a  chronic  cerebral  haemorrhage,  apparently  by  contre- 
coup.  In  other  recorded  cases  there  has  been  pachymeningitis,  or  degeneration 
of  the  tracts. 

The  prognosis  in  cases  of  apparent  traumatic  neurasthenia  and  hysteria  must 
take  these  rare  sequences  into  account,  and  a  careful  search  must  be  made  for 
the  stigmata  of  organic  disease.  If  any  one  of  the  following  is  present,  the 
prospect  of  cure  is  very  uncertain — optic  atrophy,  optic  neuritis,  marked  muscular 
wasting,  reaction  of  degeneration,  absent  knee-jerks,  extensor  plantar  response, 
anaesthesia  confined  to  the  anatomical  distribution  of  a  nerve  or  spinal  segment, 
incontinence  of  urine  or  faeces.  Trophic  lesions,  unless  artificial,  and  ankle 
clonus  are  suspicious  of  organic  disease,  but  not  conclusive. 

If  evidence  of  gross  changes  cannot  be  found,  the  patient  will  almost  certainly 
recover,  but  it  may  be  a  long  business.  Traumatic  hysteria  is  much  more 
amenable  than  traumatic  neurasthenia.  Settlement  of  any  financial  or  compen- 
sation claim  usually  leads  to  rapid  improvement,  and  this  must  not  be  inter- 
preted to  mean  that  the  patient  was  shamming.  Given  such  settlement,  the 
traumatic  neuroses  are  usually  well  wdthin  a  year  ;  but  it  must  be  admitted 
that  in  a  few  cases,  even  where  there  is  no  question  of  compensation,  the  patient's 
courage  and  morale  appear  to  be  permanently  impaired. 

2.  Fracture  or  Dislocation  of  the  Spine,  apart  from  Operation. — In  general,  a 
fracture  or  dislocation  of  the  spine  leads  to  crushing  of  the  spinal  cord,  paralysis, 
anesthesia,  and  sphincter  troubles.  If  the  injury  is  high  up,  death  results 
within  a  few  hours  or  days,  from  interference  wdth  breathing  ;  if  above  the 
fourth  cervical  vertebra,  the  patient  usually  dies  on  the  spot.  If  the  fracture  is 
low  down,  the  patient  lingers  in  a  pitiful  condition  for  months,  sometimes  as 
long  as  two  or  three  years,  and  dies  at  last  of  cystitis  leading  to  surgical  kidney, 
bedsores,  or  bronchitis.  Much  depends  on  the  care  with  which  he  is  looked 
after.  Degenerative  changes,  sometimes  called  '  mj^elitis,'  appear  to  take 
place  sooner  or  later  in  a  spinal  cord  which  has  been  crushed  severely,  and  these 
changes  may  spread  up  towards  the  brain. 

Burrell  has  pubhshed  a  record,  unfortunately  not  very  well  classified,  of  244 
cases  of  fractured  spine  admitted  to  the  Boston  City  Hospital  during  forty-two 


SPINE,     INJURIES     OF  481 


years.  He  does  not  furnish  separate  figures  for  those  patients,  13  per  cent  of 
the  whole,  who  displayed  no  paralysis,  nor  for  the  cases  operated  on.  Of  the 
244  cases,  about  two-thirds  died  in  hospital.     Period  when  deaths  took  place  : — 

Under  five  days 
Five  to  ten  days 
Ten  to  thirty  days 
Later  ... 


Of  the  '  recoveries  '  (that  is,  sent  out  of  hospital  still  alive),  62  per  cent 
were  '  useful,'  and  38  per  cent  '  useless.'  Therefore,  of  100  cases,  two-thirds 
die  within  a  month  or  two,  one-fifth  recover  sufficiently  to  get  about,  and  the 
remainder  hnger  in  a  helpless  condition. 

Classifying  the  results  according  to  the  region  affected  : — 

Cervical        -  -  85-7  per  cent  died  in  hospital. 

Upper  dorsal  -  767        ,,  ,, 

Lower  dorsal  -  56-1        „  „  ,, 

Lumbar        -  -  50  ,,  „  ,, 

We  turn  now  from  the  darker  to  the  more  favourable  picture,  and  consider  what 
are  the  cases  that  recover. 

Concussion  of  the  Cord. — There  are  undoubtedly  patients,  of  which  the  writer 
has  seen  one,  who,  with  or  without  a  bony  injury  to  the  spinal  column,  are  com- 
pletely paralyzed  and  anaesthetic  up  to  the  umbilicus  when  first  seen,  and  yet 
they  recover  perfectly  within  a  few  hours  or  days.  Corner  relates  five  such  ; 
in  all  there  was  evidence  of  fracture  or  dislocation.  Some  recovered  power  and 
sensation  within  twenty  minutes.  In  a  sixth  case,  the  patient,  an  old  man, 
kicked  in  the  back  by  a  horse,  was  completely  paralyzed  and  anaesthetic,  and 
died  in  two  days  ;  but  at  the  autopsy  there  was  no  sign  of  injury  either  to  the 
spine  or  cord.  The  patient  seen  by  the  writer  was  admitted  with  complete 
loss  of  power  and  sensation,  coming  on  instantly  at  the  time  of  the  blow  ;  but  he 
was  well  enough  to  walk  home  in  a  week  !  It  does  not  appear  to  be  possible  to 
tell  on  first  seeing  the  patient  whether  his  paralysis  is  due  to  concussion  or  to 
gross  organic  destruction  ;  but  if  recovery  is  going  to  take  place,  it  will  do  so 
within  a  week,  and  usually  there  is  great  improvement  within  a  day  or  two. 

Fracture  or  Dislocation  of  the  Cervical  Spine  used  to  be  considered  a  necessarily 
fatal  injury  ;  but  since  the  introduction  of  skiagraphy,  many  cases  have  been 
observed,  of  which  the  writer  can  recollect  seeing  three,  in  which  recovery  took 
place,  though  some  pain  and  stiffness  of  the  neck  remained.  Fritzsche  collected 
from  the  literature  up  to  1912  as  many  as  40  cases  of  fracture  of  the  odontoid 
process  ;  27  died  and  13  recovered.  Boeckel  has  furnished  a  monograph  on 
fractures  and  dislocations  of  the  neck,  showing  that  the  best  results  are  to  be 
obtained,  when  the  cord  is  not  pressed  on,  by  immediate  reduction  under  chloro- 
form, or,  better,  by  continuous  extension  ;  if  nothing  is  done  there  is  danger  of 
sudden  fatal  nippmg  of  the  cord.  If  paralysis  is  already  present,  laminectomy 
is  the  only  hope. 

Unilateral  dislocation  of  the  neck  is  particularly  favourable  in  that  the  cord 
often  escapes  involvement,  and  reduction  can  generally  be  effected. 

Hesmorrhage  into  the  Spinal  Cord  or  Membranes. — This  may  come  on  at  once  or 
within  a  few  hours  of  the  accident,  and  is  so  far  favourable  in  that  some  degree 
of  recovery  usually  occurs,  though  it  may  not  be  complete.     Signs  suggesting 

31 


482 


INDEX     OF    PROGNOSIS 


haemorrhage  are  :  (i)  The  onset  or  spread  of  paralysis  after  a  few  hours  ;  (2) 
The  development  of  the  syringomyelia  complex — loss  of  pain  and  temperature 
sense,  whilst  tactile  persists — indicating  a  central  haemorrhage ;  the  writer  has 
seen  a  case  ;  (3)  Spasms,  cramps,  and  hyperaesthesia,  due  to  extradural  bleeding. 
Laminectomy  may  do  good  in  these  cases. 

Injury  of  the  Cauda  Equina. — Regeneration,  sufficient  to  be  of  functional 
value,  does  not  occur  in  the  central  nervous  system,  but  it  may  take  place 
in  the  cauda  equina,  either  after  operation  and  suturing  any  divided  roots,  or 
spontaneously.  Recovery,  apart  from  operation,  is  not  likely  to  be  complete 
unless  the  involvement  of  the  roots  was  very  partial.  The  writer  has  seen  very 
considerable  improvement  take  place  in  a  month,  but  not  sufficient  to  make 
walking  possible. 

In  general  terms,  then,  it  may  be  stated  that  if  recovery  is  going  to  occur 
spontaneously  after  an  injury  to  the  spine  with  paralysis,  there  will  be  marked 
improvement  in  a  month,  and  usually  in  a  fortnight.  After  this,  there  is  little 
or  no  hope  of  further  benefit. 

It  must  be  borne  in  mind  that,  in  cases  of  fractured  or  dislocated  spine  in 
which  the  cord  has  escaped,  great  care  must  be  exercised  for  months,  or  the 
bones  may  slip  and  nip  it.     Burrell  relates  an  instructive  example  of  this. 

3.  The  Value  of  Laminectomy. — In  the  great  majority  of  cases  of  fractured 
spine,  the  cord  is  hopelessly  nipped  at  the  moment  of  the  accident,  and  nothing 
will  ever  restore  it.  This  unfortunate  fact  dominates  the  situation.  Neither 
in  man  nor  in  animals  does  functional  restoration  occur  after  suture,  although 
Marinesco  and  others  have  demonstrated  some  histological  regeneration  of  fibres. 
Nevertheless,  realizing  the  hopelessness  of  the  situation  in  many  cases  apart 
from  operation,  the  surgeon  is  often  tempted  to  employ  it  as  a  last  chance. 

The  mortality  of  the  operation  itself  is  not  high.  Thorburn  had  3  deaths  in 
49  cases  under  his  own  care,  including,  however,  laminectomy  for  all  sorts  of 
conditions  ;  he  lost  none  of  the  16  patients  on  whom  he  operated  for  injury 
after  the  lapse  of  some  weeks.  In  Lloyd's  series  of  cases  from  the  literature  up 
to  1901,  the  mortality  of  the  immediate  operation  was  48  out  of  82,  or  57  per 
cent,  and  of  the  late  operation  11  out  of  103,  or  about  11  per  cent.  These 
statistics  need  correcting ;  being  literature  records,  they  may  be  too  good  ;  but 
as  they  go  far  back,  they  may  be  too  bad.  We  may  probably  conclude  that  the 
mortality  of  the  early  operation  is  high,  and  of  the  late  operation  about  5  to  10 
per  cent.  Care  must  be  taken  to  avoid  infection,  especially  if  the  patient  has 
incontinence. 


Statistics  of  Laminectomy  for  Fractured   Spine  (Lloyd,  1909). 


CEKVICAL 

1 

Dorsal 

Lumbar 

Sacral 

Im- 
mediate 

Late 

Im- 
mediate 

Late 

Im- 

mediate 

Late 

Im- 
mediate 

Late 

Died  early 
Recovery 
Improvement 
No  improvement 
Died  later 

21 
0 

0 
4 

27 

2 
2 
1 
4 
3 

23 
4 
i) 
() 

7 

5 
10 
18 
16 
10 

4 
1 
1 
0 
0 

4 
() 
6 
4 
2 

0 

0 
0 
0 
0 

0 

1 

3 
0 
0 

Total     - 

12 

4!) 

65 

6 

22 

0              4 

SPINE,     INJURIES     OF 


483 


Summary. 


Cases 

Died 

Eecovered 

Improved 

Not 
improved 

Died  later 

Immediate   operation 
Late  operation 

82 
103 

48 
U 

5 
19 

12 
28 

6 
24 

11 
21 

When  we  inquire  concerning  the  end-results,  the  records  are  not  very  promis- 
ing. Thorburn  himself  operated  5  times  within  a  day  or  two  of  the  accident, 
but  none  of  the  patients  were  benefited  ;  he  collected  records  of  200  more  cases, 
without  finding  evidence  that  any  were  improved  by  the  operation.  Some,  it 
is  true,  did  get  better  ;  but  they  might  equally  well  have  done  so  without  inter- 
ference. 

Lloyd,  from  his  study  of  the  literature,  found  that  out  of  83  cases  operated  on 
early,  only  5  could  be  described  as  more  or  less  cured,  and  12  improved  ;  it  is 
not  possible  to  say  how  much  better  they  would  have  got  without  operation, 
but  the  figures  do  not  compare  well  with  those  of  the  non-operated  series,  where 
one-fifth  obtained  '  useful  '  recovery.  Except  in  a  few  urgent  cases,  such  as 
pressure  on  the  cervical  cord,  early  operation  is  not  to  be  advised. 

The  late  operation,  usually  a  month  or  six  weeks  after  the  accident,  gives 
better  results  in  well-chosen  cases.  The  immediate  risk  is  much  less,  and  as  by 
this  time  it  is  evident  how  much  or  how  little  one  may  expect  from  nature, 
any  improvement  resulting  is  more  certainly  due  to  the  operation.  Thorburn 
has  performed  16  laminectomies  under  these  circumstances,  with  4  cures,  7 
improved,  and  5  no  better.  In  Lloyd's  series,  nearly  one-fifth  are  described  as 
having  recovered,  and  one-fourth  improved.  Unfortunately,  mere  improve- 
ment is  not  much  use  to  these  patients,  unless  they  are  able  to  stand  or  walk. 
In  the  majority  of  cases  there  was  no  benefit  conferred. 

Nevertheless,  it  is  evident  that  in  a  few  picked  cases  considerable  good  may  be 
done.  Exactly  which  these  cases  are  is  shown  less  by  the  statistics  than  by 
experience  and  by  a  few  isolated  reports.  Laminectomy  may  do  good  in  the 
following  classes  : — 

a.  Fracture  or  dislocation  of  the  neck  with  pressure  on  the  cord,  where  death 
stares  the  patient  in  the  face. 

b.  Pressure  on  the  cauda  equina,  because  in  the  nerve-roots  regeneration  is 
possible.  Thorburn  advises  delay  for  six  weeks  to  see  what  spontaneous  recovery 
will  do,  and  quotes  a  case  of  Tufher's,  in  which  complete  cure  followed  lamin- 
ectomy and  suturing. 

c.  Depressed  fracture  of  a  lamina,  which  can  be  removed.  Schede  obtained 
complete  recovery  in  such  a  case,  although  when  first  seen  the  patient  was  quite 
paralyzed  and  anaesthetic.     Other  surgeons  have  not  had  such  happy  results. 

d.  Cases  of  hsemorrhage  into  the  membranes. 

e.  Cases  in  which  retention,  or  exaggeration  of  the  reflexes,  shows  that  the 
functional  continuity  of  the  cord  is  not  destroyed,  but  that  it  may  be  suffering 
injurious  pressure. 

4.  Gunshot  and  Other  Wounds  of  the  Cord. — As  Makins  has  pointed  out,  with 
modern  rifle  bullets,  in  nine  cases  out  of  ten  the  cord  is  not  actually  traversed, 
but  irretrievable  damage  is  done  by  contusion,  concussion,  or  haemorrhage.  In 
the  slighter  cases  of  concussion,  recovery  follows  in  a  few  days,  but  usually  there  • 
is  complete,  permanent,  flaccid  paralysis,  for  which  nothing  affords  any  hope  ; 
there  is  great  shock,  and  all  die  in  a  few  months,  if  not  sooner. 

If  natural  recovery  does  not  occur  within  a  few  days,  the  only  prospect  of 


484  INDEX     OF     PROGNOSIS 

7" 
betterment  is  offered  by  laminectomy,  and  that  is  only  indicated  in  a  minority 
of  the  cases.     Makins  quotes  three  such  indications  : — 

a.  Low  velocity  bullet  shown  by  the  x  ra^'s  to  be  retained  in  the  canal  and 
pressing  on  the  cord. 

b.  Excessive  pain. 

c.  Signs  of  an  incomplete  division. 

In  this  connection  mention  should  be  made  of  the  famous  Stewart-Harte  case, 
in  which,  according  to  the  report,  the  spinal  cord  of  a  young  woman  was  com- 
pletely divided  by  a  revolver  shot ;  laminectomy  and  suturing  were  performed 
in  three  hours,  and  she  recovered  sufficiently  to  be  able  to  stand. 

References. — Lloyd,  Jour.  Amer.  Mei.  Assoc.  1901,  1014,  iiii,  1247;  Thorburn, 
"Injuries  of  the  Spine,"  Burghard's  System  of  Operative  Surgery  ;  Fritzsche,  Deut.  Zeil. 
Chir.  1912,  7  ;  Boeckel,  Rev.  de  Chir.  1911,  285  ;  Corner,  Lancet,  1906,  ii,  784;  Burrell , 
Ann.  Surg.  1905,  xlii,  481.  ^.  Rendle  Short. 

SPINE,  TUMOURS  OF — We  shall  include  under  this  heading  growths  of  the 
vertebral  column,  and  also  of  the  spinal  cord. 

Tumours  of  the  Vertebral  Column. — Growths  arising  in  the  bony  spine  are 

almost  invariably  malignant,  either  primary  sarcoma  or  secondary  carcinoma. 
At  first  they  are  likely  to  be  confused  with  an  early  case  of  tuberculosis  of  the 
spine,  presenting  only  pain  and  localized  rigidity,  without  abscess  formation  or 
angular  deformity.  The  skiagram  may  be  helpful,  and  especially  a  history  of 
carcinoma  elsewhere. 

When  the  diagnosis  is  established,  the  prognosis  is  practically  hopeless.  After 
a  few  months  of  great  pain  and  helplessness,  the  patients  die.  The  cord  may 
eventually  be  pressed  on. 

Hydatid  disease  of  the  lumbar  vertebrae  may  simulate  tumour,  and  in  this 
case  a  successful  result  may  follow  operation.  Of  five  cases  of  hydatid  disease  of 
the  spine  treated  by  operation  at  the  Queen  Square  Hospital,  all  have  done  well. 

Tumours  of  the  Spinal  Cord. — The  diagnosis  of  these  cases  usually  rests  upon 
progressive  signs  of  paralysis,  anaesthesia,  and  sphincter  trouble  due  to  pressure 
on  the  cord,  associated  with  severe  pain,  and  in  many  cases  the  s^'^mptoms  are 
at  first  unilateral.  As  it  is  difficult  or  impossible  to  make  a  clinical  distinction 
between  the  signs  of  spinal  cord  tumour  and  those  of  localized  or  diffuse 
spinal  serous  meningitis,  these  are  taken  together. 

Apart  from  operation,  the  cases  are  always  fatal  within  a  few  years.  The 
average  duration  of  life  is  said  to  be  16  months  (Starr)  to  2  years  (D.  Armour), 
but  a  few  go  on  for  several  years.  Rarely,  iodides  improve  matters  somewhat. 
There  is  generally  a  steady  progress  from  root  pains  to  pressure  on  the  cord, 
then  to  sphincter  troubles,  cystitis,  bedsores,  etc. 

Tumours  of  the  Spinal  Cord.     Operation  INIgrtality. 


Reporter 

Cases 

Deaths 

Thorburn  (personal) 

Von  Eiselsberg  and  Ranzi     - 

Hunt  and  Woolsey 

Harte  (from  the  literature)     - 

Potel  and  Veaudeau  (literature) 

6 
17 

7 
92 
55 

0 
2 
1 

26 
19 

Total   ^      - 

177 

48 

SPINE,     TUMOURS     OF 


485 


Treatment  by  Operation. — Although  tumours  of  the  spinal  cord  are  not  so 
common  as  tumours  of  the  brain,  the  results  of  treatment  are  much  more  satis- 
factory. All  observers  agree  that  sarcoma  is  the  type  of  growth  most  frequently 
met  with,  but  if  the  microscopical  diagnosis  is  to  be  relied  upon,  sarcoma  in 
this  situation  must  be  of  a  very  benign  type,  because  recurrence  is  the  exception, 
not  the  rule. 

The  operation  mortality  is  not  very  serious  at  the  present  da3^  The  general 
death-rate  of  the  operation  of  laminectomy  for  all  causes  is  given  by  Thorburn 
as  the  result  of  49  cases  in  his  own  practice,  as  6  per  cent. 

The  table  on  previous  page  gives  the  mortality  of  laminectomy  for  tumour. 

When  followed  for  a  long  period,  17  more  of  Harte's  series  died,  but  his  figures 
could  probably  be  improved  upon  at  the  present  day  ;  the  true  mortality  may 
be  between  10  and  20  per  cent.  About  half  the  cases  seen  are  suitable  for 
removal ;  of  the  remainder,  some  growths  start  in  bone,  others  are  very 
extensive,  or  the  cord  is  already  destroyed. 

The  end-results  are  very  satisfactory.  R.  T.  Williamson,  by  picking  successful 
cases  out  of  the  literature,  is  able  to  give  details  of  51  patients,  17  of  them  having 
had  a  sarcomatous  tumour,  in  whom  practically  complete  recovery  took  place  ; 
that  is,  they  were  all  able  to  walk,  but  a  few  still  showed  some  spasticity  or  ataxia. 

The  following  table  gives  the  end-results  in  a  few  small  series  : — 


Tumours   of  the  Spinal  Cord.  End-Results  of  Operation. 


Reporter 

Cases  followed 

Cured 

Improved 

Not  Improved 

Recurred 

Thorburn 

Von     Eiselsberg     and 

Ranzi 
Hunt  and  Woolsey 
Harte  (from  literature) 

0 

10 

5 

49 

5 
0 

3 

29 

1 

6 
0 

17 

0 

1 

0 
3 

0 

0 
2 

? 

Total 

70 

40 

24 

4 

2 

Thorburn  records  6  cases  from  his  own  practice,  of  which  5  were  well  enough 
to  go  back  to  work. 

In  von  Eiselsberg's  series,  in  3  cases  no  tumour  was  found  ;  two  of  these  were 
improved,  and  one  was  not  improved. 

Hunt  and  Woolsey  relate  5  cases  ;  one  recurred  and  had  a  second  operation 
four  years  later,  but  has  since  remained  well  for  years  ;  another  recurred  a  year 
after  operation.     The  other  3  were  well  three  to  five  years  after  operation. 

Harte's  series,  drawn  from  a  study  of  the  literature  up  to  1905,  does  not  show- 
how  long  the  cases  were  followed,  nor  how  many  recurred,  but  he  states  that 
many  cases,  even  of  sarcoma,  were  well  years  afterwards.  Out  of  37  patients 
with  sarcomatous  tumours  of  the  cord,  20  died,  8  were  cured,  7  improved,  and 
2  no  better.     In  12  of  his  cases  only  adhesions  or  cysts  were  found. 

We  may  conclude,  then,  that  about  half  the  cases  of  tumour  of  the  spinal  cord 
are  operable  ;  that  the  operation  mortality  is  about  10  to  20  per  cent :  of  patients 
recovering  from  the  operation,  two-thirds  are  cured,  and  only  about  one  in  ten  fails 
to  benefit  or  relapses  ;    and  that  sarcoma  in  this  situation  is  remarkably  benign. 

References. — R.  T.  Wiliamson,  Diseases  of  the  Spinal  Cord,  1911  ;  Thorburn, 
"  Spinal  Cord,'  Burghard's  System  of  Operative  Sxirgery  ;  Von  Eiselsberg  and  Ranzi,  Arch, 
f.  klin.  Chir.  1913,  309  ;  Hunt  and  Woolsey,  Ann.  Surg.  1910,  lii,  289  ;  Harte,  Ann. 
Surg.  1905,  xlii,  524.  A.  Rendle  Short 


486  INDEX     OF     PROGNOSIS 

SPLEEN,  INJURIES  OF. — [See  Abdominal  Injuries.) 
SPLENIC  ANEMIA.— (See  Anemia,  Splenic.) 
SPLENOMEGALIC   POLYCYTHiEMIA.— (See   Polycyth.^jmia.) 
SPRAINS. — [See  Joints,  Injuries  of.) 
SPRUE.— (See  Colitis.) 

STOMACH,  MEDICAL  AFFECTIONS  OF  THE. 

Acute  Gastritis. — The  prognosis  depends  very  greatly  on  the  cause  and 
intensity  of  the  catarrh.  If  due  to  microbic  causes,  the  gastric  symptoms  may 
only  be  the  local  manifestations  of  a  general  disease,  such  as  enteric  fever. 

Uncomplicated  acute  gastric  catarrh  is  generally  well  in  a  few  days,  but  may 
last  for  a  week  or  longer. 

Toxic  Gastritis,  i.e.,  the  gastritis  produced  by  the  ingestion  of  various  poisonous 
substances  such  as  concentrated  acids  and  alkalies,  arsenic,  phosphorus,  per- 
chloride  of  mercury  and  so  on.  The  prognosis  in  each  case  depends  on  the  amount 
taken,  the  concentration,  and  the  particular  poisonous  action  of  each  substance. 
A  fatal  result  may  occur  in  two  or  three  hours,  the  patient  becoming  cyanosed, 
with  embarrassed  respiration,  and  dying  with  convulsions,  suffocation,  or 
collapse.  On  the  other  hand,  he  may  die  in  a  few  days'  time  from  perforation 
and  peritonitis,  or  later  on  from  remote  effects  such  as  stenosis  of  the  oesopha- 
gus, stomach,  or  pylorus.  Lastly,  he  may  die  from  the  poisonous  effects  of 
the  particular  substance  taken. 

Chronic  Gastritis. — -Before  any  satisfactory  prognosis  can  be  given  in  chronic 
gastritis  it  is  necessary  that  a  certain  diagnosis  should  have  been  made,  and 
the  possibility  of  malignancy  or  pernicious  anjemia  excluded.  Per  se  it  may 
last  for  an  indefinite  number  of  years ;  but  some  cases  are  complicated  by 
subsequent  carcinoma  of  the  organ.  In  very  rare  cases  a  tumour  may  be  felt 
in  simple  cirrhosis  of  the  stomach,  death  eventually  being  due  to  asthenia 
following  emaciation  and  anaemia. 

Diffuse  Phlegmonous  Gastritis  is  almost  certainly  alwa^^s  fatal,  the  course 
of  the  disease  being  less  than  a  week. 

Membranous  Gastritis  being  almost  always  secondary  to  some  other  severe 
illness,  the  prognosis  depends  on  that  of  the  primary  disease,  though  not  infre- 
quently this  complication  is  a  terminal  lesion. 

Carcinoma. — The  prognosis  depends  on  the  type  of  the  growth,  its  rate  of 
progress,  tendency  to  ulceration,  and  the  rapidity  with  which  secondary  deposits 
arise.  Unless  the  tumour  can  be  removed  by  surgical  means,  death  is  inevitable. 
This  in  very  rare  cases  may  be  delayed  as  long  as  four  years,  but  in  the  great 
majority  of  cases  is  very  much  less.  An  average  duration  of  life  after  the 
disease  is  first  diagnosed  is  about  seven  or  eight  months.  In  very  exceptional 
cases  the  patient  may  increase  in  weight  after  a  preliminary  wasting.  In  one 
of  the  writer's  cases,  a  temporary  gain  in  weight  of  eleven  pounds  in  sixteen 
days  occurred  in  an  emaciated  woman,  the  subject  of  carcinoma.  The  intensity 
of  the  pain  is  no  guide  to  the  prognosis,  since  it  bears  no  relation  to  the 
rate  of  extension,  or  size  of  the  growth. 

It  is  unusual  for  haematemesis  to  be  the  cause  of  death  in  carcinoma  of  the 
stomach,  though  this  may  arise  from  deep  ulceration,  or  even  from  involvement 
of  the  spleen.  The  onset  of  complications  due  to  the  invasion  of  other  organs 
by  secondary  growths  frequently  hastens  the  end.  Among  the  most  important 
of  these  are  jaundice  from  involvement   of   the   liver  or  of  the   glands   in  the 


STOMACH,     MEDICAL     AFFECTIONS    OF    THE  487 

transverse  fissure,  and  ascites  from  involvement  of  the  peritoneum.  Perforation 
may  give  rise  to  general  peritonitis,  according  to  some  authors,  in  as  many  as 
5  to  7  per  cent  of  cases.  If  the  growth  is  surrounded  by  adhesions,  an  abscess, 
sometimes  subphrenic,  is  responsible  for  the  fatal  result. 

Congenital  Hypertrophy  of  the  Pylorus  {See  Pylorus,  Congenital  Stenosis 
of). — About  50  per  cent  recover  without  subsequent  complications.  With  an 
earlier  recognition  of  the  disease  the  proportion  of  recoveries  will  probably  be 
much  greater.  In  Still's  series  of  27  cases,  about  50  per  cent  recovered,  8  after 
operation  and  6  after  medical  treatment,  which  included  daily  gastric  lavage 
with  a  weak  alkaline  solution. 

Ulcer. — Correct  statistics  in  connection  with  gastric  ulcer  are  almost 
impossible  to  obtain,  because  of  the  difficulty  of  a  certain  diagnosis.  This 
applies  not  only  to  observations  made  during  life,  but  also  to  statistical  records 
based  on  post-mortem  investigations,  because  cicatrices  of  small  ulcers  which 
have  healed  are  readily  overlooked,  and  very  slight  ulceration  may  have  healed 
without  leaving  any  scar. 

Speaking  generally,  the  prognosis  of  gastric  ulcer  treated  by  thorough  and 
prolonged  medical  treatment  is  satisfactory.  Statistical  figures  vary,  however, 
within  somewhat  wide  limits.  Leube  gave  the  death-rate  as  24  per  cent  in 
424  cases,  but  eventually  he  brought  down  his  mortality  to  0-3  per  cent.  Lebert 
gave  the  mortality  as  10  per  cent,  J.  W.  Russel  as  6-4  per  cent,  Bulstrode  as 
18  per  cent,  Fleiner  as  o  per  cent  in  300  cases,  and  Weitrand  as  o  per  cent  in 
133  cases.  Possibly  about  6  to  7  per  cent  of  cases  perforate  into  the  peritoneal 
cavity,  but  the  prognosis  of  this  calamity  has  enormously  improved  within 
recent  years,  owing  to  the  advance  of  surgical  technique.  Local  abscess,  sub- 
phrenic or  elsewhere,  may  lead  to  death  by  exhaustion,  pyaemia,  or  pylephlebitis. 
In  rare  cases,  the  abscess  bursts  into  the  lung,  pleura,  or  pericardium.  Probably 
less  than  3  per  cent  of  the  cases  succumb  from  haemorrhage,  and  another  5  to  6  per 
cent  from  other  causes,  including  inanition,  secondary  mechanical  deformities, 
and  carcinoma.  The  mortality  from  haemorrhage  in  Lenhartz's  series  of  295 
cases  was  i  per  cent,  and  in  Ewald's  652  cases  1-2  per  cent.  Spriggs  found  that 
the  prognosis  with  reference  both  to  life  and  recurrence  of  haemorrhage  was 
more  favourable  in  patients  treated  by  Lenhartz's  method  than  in  those  treated 
by  nutrient  and  saline  enemata  followed  by  a  graduated  milk  diet.  Relapse 
is  very  frequent,  and  probably  occurs  in  not  much  less  than  30  per  cent.  After 
surgical  treatment,  as  after  medical,  relapse  is  not  infrequent,  but  the  tendency 
to  relapse  after  any  method  of  treatment  is  less  after  the  age  of  thirty  than 
before.  Although  it  is  unusual  for  a  patient  to  die  from  a  single  attack  of 
haemorrhage,  this  occasionally  occurs,  sometimes  so  rapidly  that  the  patient 
succumbs  before  vomiting  takes  place.  According  to  Spriggs,  the  mortality 
of  any  large  series  of  cases  operated  on  for  haemorrhage  is  greater  than  it  is  in  a 
similar  series  not  operated  on. 

About  50  per  cent  of  the  cases  are  permanently  cured.  Anaemia  from  any 
cause  retards  the  healing  of  an  ulcer,  and  a  patient  with  a  healed  ulcer  is  always 
liable  to  relapse  as  long  as  anaemia  persists.  The  percentage  of  cases  of  cancer 
of  the  stomach  which  owe  their  origin  to  previous  ulceration  varies  in  different 
statistics  from  2-3  per  cent  up  to  9  per  cent. 

Syphilis  of  the  Stomach. — This  affection  may  very  closely  simulate  gastric 
ulcer  or  malignant  growth.  The  prognosis,  therefore,  very  largely  depends 
on  a  correct  diagnosis.  If  this  is  made  early,  before  the  patient  is  suffering 
from  excessive  debility  owing  to  the  mechanical  effects  of  the  tumour,  or  from 
dense  adhesions  or  peritonitis,  the  prognosis  is  decidedly  favourable  under 
brisk    antisyphilitic    treatment.     With    dense    adhesions    or    the    formation    of 


INDEX     OF     PROGNOSIS 


scar  tissue,  surgical  treatment  may  be  necessary.  Profuse  haemorrhage  may 
very  exceptionally  arise. 

Acute  Dilatation, — -This  may  cause  death  in  a  few  hours,  with  pain,  anuria, 
severe  symptoms  of  collapse,  associated  with  a  very  copious  and  rapid  secretion 
into  the  stomach.  A  fatal  result  is  not  uncommon  in  spite  of  energetic  treat- 
ment and  gastric  lavage.  Sudden  dilatation,  arising  from  injudicious  feeding 
during  convalescence  from  prolonged  exhausting  diseases  Uke  typhoid  fever, 
may  lead  to  immediate  death. 

Chronic  Dilatation.  —  The  outlook  depends  very  much  on  the  cause,  the 
general  health  of  the  patient,  and  the  length  of  time  the  trouble  has  existed 
before  treatment  is  adopted.  In  atonic  dilatation,  the  course  of  the  illness  is 
frequently  very  prolonged,  running  into  years,  very  frequently  with  incomplete 
restitution  of  the  normal  size  of  the  viscus  at  the  end  of  lengthy  and  careful 
treatment.  With  mechanical  obstruction,  prognosis  is  more  hopeful  if  early 
surgical  treatment  is  available.  Severe  forms  of  gastric  dilatation  may  be 
associated  with  tetany,  which,  if  well  marked,  is  of  serious  significance. 

This  condition  has,  however,  been  treated  quite  successfully  by  gastro- 
enterostomy, with  subsequent  cure  of  the  patient.  (With  reference  to  the 
prognosis  of  coincident  acidosis,  see  article  on  Acidosis.)  /.  r,  Charles. 

STOMACH,    SURGICAL    AFFECTIONS    OF    THE. 

Gastric  Ulcer.- — Our  conception  of  '  gastric  ulcer  '  has  entirely  changed  in 
recent  years  ;  formerly  considered  easy  of  diagnosis,  it  is  now  known  to  be 
difficult,  even  in  long-standing  cases.  For  this  reason  the  prognosis  of  cases 
not  verified  by  operation  is  entirely  a  matter  of  conjecture. 

Two  distinct  lesions  are  included  under  the  term  gastric  ulcer — the  acute 
ulcer,  frequently  multiple  —  called  'mucous'  by  Sir  Bertrand  Dawson,^  and 
the  indurated   chronic   ulcer,    usually  single. 

With  regard  to  the  relative  frequency  of  these,  we  are  entirelj'  in  the  dark. 
Owing  to  the  recent  extension  of  surgical  activity  in  the  upper  abdomen,  we 
now  know  that  symptoms  which  formerly  were  considered  pathognomonic  of 
gastric  ulcer  often  owe  their  origin  to  extra-gastric  causes,  and  are  entirely 
removed  by  treating  these. 

That  chronic  gastric  ulcer  is  a  serious  disease  carrying  with  it  a  very  consider- 
able mortality  is  now  becoming  well  known. 

The  results  of  the  medical  treatment  of  patients  presenting  the  symptoms 
of  chronic  gastric  ulcer  have  been  investigated  by  several.  Among  the  earliest 
figures  are  those  given  by  Bulstrode,^  who  compiled  statistics  of  all  the  cases 
of  '  gastric  ulcer  '  admitted  into  the  London  Hospital  from  January,  1897, 
to  August,  1902.  These  numbered  500,  402  women  and  98  men.  Of  these 
cases,  42  per  cent  had  had  previous  attacks.  The  death-rate  was  18  per  cent : 
10  per  cent  from  perforation,  2|  per  cent  from  hsematemesis,  5|-  per  cent  from 
other  causes.  These  figures  did  not  include  late  results  such  as  stenosis,  hour- 
glass contractions,   etc. 

That  the  mortality-rate  is  unrehable  and  much  too  low  is  evident  from  the 
sex  relationship,  402  women  and  98  men.  The  conditions  which  mimic  chronic 
gastric  ulcer  are  more  common  in  the  female  sex,  and  rarely  fatal. 

Of  the  192  cases  of  gastric  ulcer  upon  whom  I  have  operated,  119  were 
males.     This  is  in  accord  with  the  experience  of  other  surgeons. 

Habershon's^  figures  give  a  more  correct  idea  of  the  death-rate  in  cases  of 
chronic  gastric  ulcer  medically  treated.  Of  60  cases  in  private  practice,  there 
were  24  deaths,  16  males  (6  perforation,  7  haematemesis,  3  exhaustion)  and  8 
females  (5  perforation,  3  haematemesis). 


STOMACH,     SURGICAL     AFFECTIONS     OF     THE  489 

MacNevin  and  Herrick's*  figures  are  instructive.  Among  55  fatal  cases  of 
gastric  ulcer  examined  post  mortem,  25  had  died  of  haematemesis  (19  males, 
6  females)  ;   30  of  perforation  (8  males,  22  females). 

Greenhough  and  Joslin^  published  the  results  of  the  medical  treatment  of 
1 87  cases  ;  the  initial  mortality  was  8  per  cent.  After  five  years,  115  patients 
could  be  traced:  57  had  had  recurrence,  and  15  had  died  of  gastric  disease. 

Figures  based  on  the  medical  diagnosis  of  gastric  ulcer,  although  minimizing 
the  real  risks,  show  very  strongly  the  futility  of  medical  treatment  in  the 
majority  of  the  cases. 

It  is  evident  from  the  discrepancy  between  the  sex  distribution  in  the  medical 
and  surgical  statistics  that  there  are  two  distinct  conditions :  one  more  common 
in  women,  in  which  acute  ulceration  followed  by  perforation  may  occur ;  the 
other  more  frequent  in  men,  in  which  the  immediate  cause  of  death  is  not  un- 
commonly haematemesis.     In  this  group,  perforation  is  uncommon. 

The  cases  formerly  diagnosed  gastric  ulcer  in  young  women  are  usually 
examples  of  extra-gastric  disease  with,  in  many  cases,  acute  gastritis  or  mucous 
ulcers  the  result  of  septic  infection.  The  relation  between  the  two  groups  is 
at  present  obscure,  but  it  seems  certain,  from  the  sex  incidence  of  chronic  lesions, 
that  in  the  majority  of  cases,  although  symptoms  recur,  chronic  gastric  ulcer 
does  not  follow.  Careful  medical  treatment  of  this  group  of  case,  if  the  condition 
causing  the  gastric  disturbance — septic  teeth  or  chronic  constipation — can  be 
dealt  with,  is  successful,  but  if  disease  of  the  gall-bladder  or  the  appendix  is 
responsible,  treatment  of  these  alone  wiU  cure. 

In  chronic  gastric  ulcer,  in  addition  to  the  dangers  from  haemorrhage,  per- 
foration, and  malnutrition  the  result  of  stricture,  there  is  the  appreciable  risk 
of  the  development  of  carcinoma.  Considerable  difference  of  opinion  exists 
with  regard  to  the  frequency  with  which  this  occurs. 

The  most  widely-quoted  figures  are  those  of  Wilson  and  MacCarty,*  obtained 
as  the  result  of  their  examination  of  specimens  removed  by  operation  in  the 
Mayo  clinic.  In  109  out  of  153  cases  (71  per  cent)  there  was  evidence  that 
malignant  disease  had  supervened  on  chronic  gastric  ulcer. 

On  the  other  hand,  in  30  consecutive  cases  in  which  I  have  excised  chronic 
gastric  ulcers,  diagnosed  at  operation  as  simple,  I  have  had  serial  sections 
examined  microscopically,  and  in  one  only  was  any  trace  of  malignant  develop- 
ment perceptible. 

Burk'  records  24  cases  of  excision  of  chronic  gastric  ulcers,  in  6  of  which 
microscopic  examination  revealed  early  malignancy. 

Looking  at  the  subject  from  the  clinical  standpoint,  I  have  operated  upon 
112  cases  of  gastric  carcinoma,  33  only  of  whom  were  women;  this  fact  is 
suggestive.  In  over  a  third  of  the  cases  (41)  I  obtained  a  history  of  gastric 
disease,  on  which  I  should  base  the  diagnosis  of  chronic  gastric  ulcer  extending 
over  more  than  five  years. 

Although  the  frequency  has  probably  been  over-stated,  I  think  there  can  be 
no  doubt  whatever  that  previous  gastric  disease  is  a  predisposing  cause  of 
carcinoma. 

Thorough  medical  treatment  after  removal  of  septic  foci  during  the  first 
attack  of  gastric  symptoms  can  be  expected  to  result  in  cure  in  30  to  40  per 
cent  of  the  cases.  If  relapse  occurs  it  is  obvious  that  the  exciting  cause  is 
beyond  medical  assistance.  If  chronic  ulcer  has  developed,  medical  treatment 
appears  to  be  a  failure  in  every  case. 

Perforalion. — The  prognosis  depends  upon  the  time  at  which  operation  is 
carried  out.  If  within  twenty-four  hours,  the  death-rate  should  certainly  be 
below  10  per  cent.     The  older  figures,  which  are  widely  quoted,  are  much  too 


490  INDEX     OF    PROGNOSIS 

high.  Gross  and  Gross^  found  the  death-rate  of  operation  in  collected  cases 
within  the  first  twenty-four  hours  to  be  50  per  cent,  and  within  the  first  tvvelve 
25  per  cent  a  figure  which  agrees  closely  with  those  given  by  Brunner  f  these 
closely  correspond  with  the  personal  figures  of  Miles,  i"  in  1906:  19  cases  within 
twelve  hours  of  operation,  26-3  per  cent  mortality;  9  cases  between  twelve 
and  twenty-four,  44-4  per  cent  mortality. 

Sinclair  Kirk"  has  recorded  a  series  of  11  cases  operated  on,  10  before  the 
twelfth  hour,  and  i  at  twenty  hours,  with  recovery  in  all. 

Of  10  cases  upon  whom  I  have  operated  within  the  first  twenty-four  hours, 
all  recovered.  On  the  other  hand,  in  18  cases  over  this  period,  there  were  12 
deaths. 

The  immediate  result  of  operation  in  these  cases  is  excellent,  but  a  certain 
number  suffer  later  from  dyspeptic  symptoms  similar  to  those  from  which 
the  majority  suffered  before  perforation.  There  is,  however,  considerable 
difference  of  opinion  with  regard  to  this.  Hale  White^^  said  :  "  Judging  from 
our  results  at  Guy's  Hospital,  it  appears  that  patients  who  survive  an  operation 
for  perforated  gastric  ulcer  do  so  well  that  a  gastrojejunostomy  is  quite  un- 
necessary." This  is,  however,  not  the  "experience  of  surgeons  if  the  word 
'operation'  is  used  instead  of  gastrojejunostomy. 

Paterson  found  that  23  per  cent  of  patients  relapse  within  a  year  of  operation. 

It  is  obvious  that  as  the  ulcer  which  perforates  is  a  chronic  one  in  only  a 
small  proportion  of  cases,  the  continuance  of  the  symptoms  depends  upon 
extra- gastric  causes. 

If  the  ulcer  which  perforates  is  a  chronic  one,  gastrojejunostomy  should  be 
done  at  the  time  of  closure  of  the  perforation,  if  the  condition  of  the  patient 
will  allow.  This  I  was  able  to  carry  out  in  6  cases  who  have  had  no  further 
return  of  symptoms.  Four  of  the  remaining  10  who  recovered  have  had 
symptoms  necessitating  further  operation. 

Prolonged  medical  treatment  in  those  cases  in  which  gastrojejunostom3' 
is  not  carried  out,  will  still  further  lower  the  number  of  cases  requiring  further 
operation. 

Hcsmatemesis. — Dr.  Cecil  WalP^  found  that  6  per  cent  of  the  men  and  12 
per  cent  of  the  women  who  were  admitted  to  the  London  Hospital  suffering 
from  chronic  gastric  ulcer,  diagnosed  clinically,  died  of  this  complication.  The 
death-rate  is  far  in  excess  of  this,  for  included  are  many  cases  which  were 
certainly  not  chronic  gastric  ulcer.  This  is  shown  by  all  reports  of  post-mortems, 
while  hsematemesis  is  undoubtedly  more  common  in  women  than  in  men. 
Thus  MacNevin  and  Herrick  found  haematemesis  to  be  the  cause  of  death  in  25 
out  of  55  cases  of  chronic  gastric  ulcer  which  came  to  post-mortem.  Of  these,  19 
were  males,  and  of  the  women,  all  except  one  were  over  thirty.  These  figures 
correspond  to  my  operative  experience  that  chronic  gastric  ulcer  is  three  times 
as  common  in  men  as  in  women. 

The  prognosis  of  the  haematemesis  of  young  women  is  extremely  good :  the 
death-rate  is  less  than  5  per  cent.  I  believe  that  life  cannot  be  saved  in  this 
condition  by  operation.  The  bleeding  often  takes  place  from  many  foci,  and 
continues  unchecked  in  spite  of  gastrojejunostomy- 

I  believe  the  death-rate  from  haematemesis  in  chronic  gastric  ulcer  is  over 
50  per  cent.  If  treated  surgically  as  soon  as  possible  after  the  first  haemorrhage, 
the  outlook  is  good.  Operation  consists  in  directly  controlling  the  source  of 
haemorrhage  by  excision  of  the  ulcer  or  tying  the  vessels  on  either  side,  combined 
with  inversion  and  gastrojejunostomy,  if  necessar}^ 

I  have  treated  seven  cases  in  this  way  with  one  death,  a  patient  in  whom  the 
haematemesis,   which   had   been   going   on  for  four  days,  was  complicated   by 


STOMACH,     SURGICAL     AFFECTIONS     OF     THE  491 

perforation.  On  the  other  hand,  death  occurred  in  three  patients  whom  I  had 
seen  and  who  had  refused  operation,  recurrence  of  bleeding  proving  fatal. 

Operation  as  soon  as  possible  after  the  first  haemorrhage — this  is  usually 
within  twenty-four  hours  in  all  cases  of  chronic  gastric  ulcer — will  render  the 
prognosis  favourable. 

Chronic    Gastric   Ulcer There  is  still  a  difference  of  opinion  with  regard  to 

the  exact  form  surgical  treatment  should  take.  The  immediate  risk,  if  the 
operation  is  carried  out  by  one  skilled  in  upper  abdominal  surgery,  is  a  small  one. 

Up  to  July  I,  1913,  I  operated  upon  164  cases  of  chronic  gastric  ulcer,  with 
4  deaths. 

The  following  were  the  operations  performed  (nineteen,  complicated  by 
hour-glass  stomach,  are  separately  tabulated)  : — 

Excision :    6  cases,  no  death. 

Excision  and  gastrojejunostomy  :  19,  i  death  (this  patient  had  urethral  stricture 
and  cystitis,  and  died  one  month  later  from  this  cause). 

Partial  gastrectomy :    4  cases,   i  death  from  acute  gastric  dilatation. 

Gastrojejunostomy  alone  :  116,  2  deaths  (one  from  haematemesis  the  result  of 
erosion  of  the  splenic  artery  two  days  after  operation,  the  other  from  pneu- 
monia nine  days  after  operation). 

In  the  nineteen  cases  of  hour-glass  stomach,  the  following  were  the  operations 
carried  out : — • 

Posterior  no-loop  gastrojejunostomy  :    10  cases,  no  death. 

Anterior  no-loop  gastrojejunostomy :  5  cases,  i  death  twelve  days  after  operation. 

No  attempt  at  union. 
Double  gastrojejunostomy  :    2  cases,  no  death. 
Modified  Roux's  operation  :    2  cases,  no  death. 

W.  J.  Mayo^*  records  428  cases  of  chronic  ulcer  of  the  stomach  operated  on 
at  the  Mayo  clinic,  with  a  mortality  of  2-4  per  cent. 

It  is  obvious  that  the  immediate  mortality  is  much  less  than  that  given  in 
any  series  of  cases  medically  treated. 

With  regard  to  the  remote  results  of  surgical  treatment,  it  is  undoubted 
that  the  majority  of  patients  with  chronic  gastric  ulcer,  wherever  situated, 
are  cured  as  the  result  of  gastrojejunostomy  alone. 

The  following  are  representative  figures  of  the  results  of  cases  operated  upon 
over  two  years  : — 

Sherren,  82  cases,  78  traced  over  two  years,  69  remain  quite  well,  2  were  re-operated 
on  and  ulcers  adherent  to  pancreas  excised.  The  remainder,  with  one  excep- 
tion, were  relieved. 

Paterson.15  After-history  of  143  collected  cases,  82  per  cent  over  two  years' 
duration. 

Petren,^*  157  collected  cases,  53  per  cent  cures,  78  per  cent  very  much  better. 

Busch,'-'  64  cases,  85  per  cent  cures. 

Kocher,!''  67  per  cent  cures.  89  per  cent,  a  good  result. 

It  is  obvious  from  these  figures  that  while  gastrojejunostomy  alone  will 
bring  about  a  cure  in  probably  70  per  cent,  and  give  great  relief  in  another  10 
or  15  per  cent,  there  is  yet  a  margin  in  which  further  improvement  is  desirable. 

Of  the  6  cases  treated  by  excision  alone,  only  2  were  operated  on  over  two 
years  ago.     Both  remain  well. 

In  many  of  the  recorded  results,  the  cause  of  the  continuance  or  recurrence 
of  symptoms  has  not  been  noted,  and  it  may  be  that  they  are  due  to  other 
conditions  overlooked  at  the  first  operation.  In  three  of  my  cases  the  '  recur- 
rence '  of  symptoms  was  due  to  gall-stones  ;  subsequent  operation  proved  that 
the  ulcers  had  healed. 

Thorough  examination  of  the  whole  abdomen,  and  gastrojejunostomy, 
combined  with  excision  or  resection   in   suitable  cases,   will  still   improve   our 


492  INDEX     OF     PROGNOSIS 


results  and  bring  about  a  lasting  cure  in  over  95  per  cent  of  the  cases  of  chronic 
gastric  ulcer,  with  a  death-rate  of  less  than  5  per  cent. 

Much  discussion  has  taken  place  with  regard  to  the  correct  operative  proce- 
dure, but  no  law  can  be  laid  down.  Cases  of  chronic  gastric  ulcer  cannot  be 
treated  by  set  operation :  the  decision  must  be  made  in  each  case  after  the 
abdomen  has  been  opened. 

In  my  experience,  cases  of  posterior  ulcer  eroding  the  pancreas  rarely  heal 
as  the  result  of  gastrojejunostomy,  and  should  be  treated  by  excision  in  addition. 

Excision  alone  may  fail.  Busch,^^  in  12  cases,  found  2  in  which  gastro- 
jejunostomy was  necessary  later.  Dobson,^"  in  10  cases,  had  to  operate  for 
recurrence  in  4,  in  2  of  which  the  appendix  had  been  removed  at  the  original 
operation. 

It  is  obvious  that  excision  alone,  even  combined  with  removal  of  appendix, 
is  not  so  satisfactory  as  gastrojejunostomy. 

Hasmorrhage  and  perforation  have  been  recorded  after  gastrojejunostomy  ; 
these  complications  may  be  avoided  by  treating  the  ulcer  directly,  either 
inverting  it  or,  in  posterior  adherent  ulcers,  performing  excision  or  resection 
combined  with  gastrojejunostomy.  In  the  patient  of  mine  in  whom  death 
took  place  from  haematemesis,  I  should,  at  the  present  time,  have  excised  the 
ulcer. 

It  has  been  pleaded  in  favour  of  excision  in  every  case  that  malignant  disease 
may  supervene,  and  that  it  is  impossible  to  tell  if  this  has  already  taken  place. 
In  none  of  my  cases  has  it  done  so,  although  Kiittner^^  states  that  5  out  of  12 
patients  (41  per  cent)  died  of  cancer  of  the  stomach,  and  that  43  per  cent  of 
ulcers  excised  were  malignant.  Busch,  on  the  other  hand,  draws  attention  to 
the  small  percentage  of  cases  in  which  this  occurs. 

Hour-glass  Stomach. — The  result  of  treatment  in  the  18  survivors  has  been 
uniformly  good.  All  remain  perfectly  well,  5  more  than  three  years,  9  over 
two  years. 

Veyrasset^-  records  181  collected  cases.  Of  these  73  were  treated  by  gastro- 
jejunostomy with  14  deaths,  6  of  which  were  due  to  an  error  in  technique, 
the  anastomosis  being  made  to  the  pyloric  pouch  distal  to  the  constriction. 
Of  the  58  survivors,  57  were  cured. 

Duodenal  Ulcer — In  duodenal  ulcer,  medical  treatment  after  the  first  attack 
is  not  only  futile  but  dangerous.  Delay  is  not  to  be  countenanced ;  the  danger 
of  perforation  is  great,  and  frequently  occurs  between  attacks  when  the  patient 
is  free  from  symptoms  and  apparently  well.  Perforation  of  a  chronic  gastric 
ulcer  is  unusual,  of  a  chronic  duodenal  one  frequent.  Perforation  of  an  acute 
duodenal  ulcer  is  rare;  it  occurred  in  only  2  cases  out  of  31  upon  whom  I 
have  operated. 

The  same  sex  predominance  is  seen  in  perforation  as  in  the  cases  operated 
on  before  this  has  taken  place  :  a  very  different  condition  from  chronic  gastric 
ulcer.  Brunner^^  found  in  341  cases  of  perforated  gastric  ulcer  only  68  men, 
whereas  in  the  unperforated  cases  the  ratio  is  3  men  to  i  woman  ;  in  the  cases 
of  perforated  duodenal  ulcer,  8  women  out  of  82,  i  to  10,  as  in  the  unperforated 
cases. 

That  the  danger  of  perforation  in  chronic  duodenal  ulcer  is  greater  than  in 
gastric  is  evidenced  from  the  figures  given  by  Gruber-*  from  post-mortem 
examination.  He  found  that  while  17  per  cent  of  the  cases  of  duodenal  ulcer 
had  died  of  perforation,  only  5-6  per  cent  of  the  gastrics  succumbed,  and  gives 
the  death-rate  of  duodenal  ulcer  as  25-5  per  cent,  of  gastric  ulcer  9-8  per  cent. 

Kiittner-^  states  that  the  prognosis  of  duodenal  is  decidedly  less  favour- 
able than  that  of  gastric  ulcer  on  account  of  the  frequency  of  perforation  and 


STOMACH.     SURGICAL     AFFECTIONS     OF     THE  493 

haemorrhage.  He  quotes  statistics  of  post-mortems  at  Hamburg  showing 
that  when  duodenal  ulcer  was  found  post  mortem  it  was  the  cause  of  death 
in  40  per  cent. 

Hsemorrhage  is  the  same  lethal  complication  as  in  cases  of  chronic  gastric  ulcer. 

While  malignant  disease  frequently  supervenes  in  cases  of  chronic  gastric 
ulcer,  this  change  is  rare  in  duodenal  ulcer. 

In  173  cases  of  chronic  duodenal  ulcer  personally  operated  on  before  per- 
foration, in  I  only  had  malignant  disease  supervened  after  a  history  pointing 
to  chronic  duodenal  ulcer  extending  over  many  years.  Moynihan^^  also  has 
recorded  an  example  in  which  malignancy  supervened  after  ten  years. 

No  case  has  been  recorded  of  carcinoma  of  the  duodenum  arising  after  gastro- 
jejunostomy. 

Perforation. — If  operation  is  carried  out  within  the  first  twenty-four  hours, 
the  prognosis  is  extremely  good. 

Sherren  :  31  cases  of  perforation  with  18  recoveries.  Of  16  operated  upon 
within  the  first  twenty-four  hours,  all  recovered  except  2,  one  of  whom  was 
suffering  from  advanced  genito-urinary  and  pulmonary  tuberculosis.  The 
other  was  a  patient  in  whom  fat  necrosis^^  was  found  at  operation,  and  a  per- 
forated ulcer  was  overlooked. 

MitchelP*  has  recorded  16  cases  operated  upon  without  a  death.  Of  these 
cases,  II  were  operated  upon  within  twelve  hours  of  perforation,  6  within  five 
hours,  I  each  at  seventeen  and  a  half,  eighteen,  twenty-five,  thirty-six,  and 
forty-nine  hours  after  perforation. 

Struthers^^  quotes  24  cases  with  19  recoveries. 

It  is  evident  that  operation  can  be  carried  out  within  the  first  twenty-four 
hours  with  a  death-rate  of  less  than  5  per  cent.  In  all  cases  in  which  a  chronic 
ulcer  perforates,  gastrojejunostomy  should  be  done  at  the  time  of  closure  of 
the  perforation.  This  I  did  in  14  of  my  cases,  only  i  of  whom  died,  the  patient 
mentioned  above.  Of  the  cases  in  which  this  was  not  carried  out,  I  have  since 
had  to  perform  it  for  recurrence  of  symptoms.  In  addition,  I  have  had  to 
treat  surgically  5  cases  after  perforation  of  a  chronic  ulcer  had  been  closed  by 
other  surgeons  and  recurrence  of  symptoms  had  taken  place. 

The  immediate  risk  of  operation  in  cases  of  non-perforating  duodenal  ulcer 
is  small.     Moynihan  reports  302  cases  operated  upon,   with  5  deaths. 

Sherren:  172  cases  with  2  deaths,  both  from  bronchopneumonia,  in  patients 
aged  sixty-three  and  sixty-five. 

Gastrojejunostomy  is  followed  by  cure  in  at  least  So  per  cent  of  the  cases. 

Of  personal  cases,  70  have  been  operated  on  over  two  years ;  65  remain  per- 
fectly well,  2  could  not  be  traced,  and  only  3  complain  of  occasional  dis- 
comfort. 

In  Moynihan's  cases,  82-78  per  cent  are  recorded  as  cured,  and  7  per  cent 
improved. 

It  is  important  to  see  that  treatment  is  carried  out  for  at  least  three  months 
after  operation. 

The  complication  most  to  be  feared  after  gastrojejunostomy  is  jejunal 
ulceration.  This  may  occur  at  the  suture  line  when  it  is  termed  gastrojejunal, 
or  in  the  jejunum  not  far  removed  from  it,  the  true  peptic  jejunal  ulcer.  The 
former  condition  is  usually  preventable  ;  it  is  due  in  the  majority  of  cases  to 
the  use  of  an  unabsorbable  inner  suture.  This  should  always  be  of  catgut. 
The  true  jejunal  ulcer  is  situated  in  most  instances  on  the  anterior  surface  of 
the  distal  limb  of  the  jejunum,  about  i  in.  from  the  anastomosis.  Very  occa- 
sionally it  is  proximal ;  in  58  cases  recorded  by  van  Roojen'"^  it  had  this  situation 
in  6  only. 


494  INDEX     OF     PROGNOSIS 

While  it  may  occur  after  an^^  variety  of  gastrojejunostomy,  it  is  most  common 
after  those  in  which  a  long  loop  is  left,  whether  anterior  or  posterior,  especially 
the  Y  type,  including  in  this,  those  cases  of  long  loop  in  which  entero-anastomosis 
has  been  carried  out. 

The  question  of  the  actual  exciting  cause  of  jejunal  ulceration  is  uncertain, 
but  it  has  undoubtedly  an  association  with  hyperchlorhydria,  is  most  often 
met  with  in  males,  and  follows  operation  for  chronic  duodenal  much  more 
frequentl}^  than  those  for  chronic  gastric  ulcer. 

As  the  probable  cause  of  jejunal  ulceration  is  similar  to  that  of  the  ulcer 
for  which  the  operation  is  carried  out,  it  is  less  likely  to  occur  if  careful  search 
is  made  at  the  time  of  the  primary  operation  for  other  foci  of  disease  in  the 
abdomen,  particularly  in  the  appendix  and  gall-bladder.  In  addition,  medical 
treatment  should  be  carried  out  for  at  least  three  months  following  operation. 
In  cases  in  which  there  is  a  great  increase  in  acidity,  it  would  be  well  to 
investigate  the  gastric  contents  from  time  to  time. 

The  question  of  the  influence  of  the  removal  of  a  diseased  appendix  upon  its 
incidence  has  not  yet  been  worked  out. 

It  is  extiemely  difficult  to  estimate  the  frequency  with  which  this  complica- 
tion arises  after  gastrojejunostomy  has  been  performed  for  gastric  or  duodenal 
ulcer.     I  beHeve  it  to  be  certainly  not  more  than  2  per  cent. 

Symptoms  usually  arise  within  the  first  two  years  ;  thus,  in  66  cases  collected 
by  van  Roojen,^"  44  occurred  within  the  first  two  years,  27  within  the  first 
twelve  months. 

In  Moynihan's  cases  of  chronic  duodenal  ulcer,  jejunal  ulcer  developed  in  2. 
It  is  interesting  to  note  that  in  the  4  cases  operated  upon  by  him,  all  had 
followed  duodenal  ulcer. 

So  far  as  could  be  ascertained,  no  example  of  jejunal  ulcer  arose  in  715  cases 
in  which  gastrojejunostomy  was  performed  for  chronic  gastric  or  duodenal 
ulcer  in  the  Mayo  clinic,^^  but  2  cases  of  gastrojejunal  ulcer,  in  one  of  which, 
however.  Murphy's  button  had  been  used,  and  it  was  retained  in  the  stomach. 
Sherren  had  5  occur  in  356  cases  in  which  gastrojejunostomy  was  performed 
for  chronic  ulcers  of  stomach  or  duodenum.  In  170  cases  of  chronic  gastric 
ulcer  this  comphcation  arose  once,  six  weeks  after  excision  of  a  chronic  ulcer 
on  the  lesser  curvature  followed  by  gastiojejunostomy. 

Among  186  chronic  duodenal  cases,  symptoms  of  jejunal  ulcer  necessitated 
operation  in  4  cases,  three  months,  six  months  (2  cases),  and  ten  months  after 
the  original  operation.  All  were  successful.  In  all,  the  acidity  had  remained 
high,  and  in  none  was  the  appendix  removed  at  the  original  operation. 

I  have  operated  also  upon  3  cases  in  which  the  operation  was  performed  by 
other  surgeons  (i  gastric,  2  duodenal).     All  the  patients  were  males. 

Gastric  Symptoms  associated  with  Disease  elsewhere  in  the  Abdomen, — 
There  are  three  groups  of  cases  in  which  gastric  symptoms  mimicking  gastric 
or  duodenal  ulcer  may  be  present  ;  they  are  due  to  disease  in  the  ileocaecal 
region,  gall-bladder,  and  urinary  organs. 

In  the  first  named  the  symptoms  may  be  due  to  disease  of  the  appendix, 
or  to  such  conditions  as  interfere  with  the  function  of  the  caecum,  terminal  ileum, 
or  ileocaecal  valve,  prolapse  and  atony  of  the  caecum,  adhesions  around  the 
ascending  colon,  or  the  presence  of  an  ileal  kink.  It  may  be  difficult  before 
operation  to  say  to  which  condition  the  symptoms  are  due,  for  they  all  bear 
a  resemblance  to  each  other.  It  is  usually  possible,  however,  to  suggest  an 
appendicular  origin,  for,  as  I  have  pointed  out,^-  pain  in  the  right  iliac  fossa 
is  an  accompaniment,  not  of  chronic  appendicitis,  but  of  interference  with 
the  function  of  the  caecum. 


STOMACH.     SURGICAL     AFFECTIONS     OF     THE  495 

Examples  of  true  appendicular  dyspepsia  do  extremely  well  after  operation. 
Up  to  December,  191 2,  I  had  operated  upon  63  patients  (38  males,  25  females) 
in  whom  the  diagnosis  of  the  cause  of  the  indigestion  could  not  be  made  with 
certainty  before  operation,  and  the  upper  abdomen  was  first  explored  before 
a  diseased  appendix  was  found  and  removed.  In  49  of  these  the  appendix 
was  of  the  atrophic  obliterative  type  so  frequently  associated  with  chronic 
gastric  and  duodenal  ulcer.  (In  83  consecutive  cases  of  ulcer  with  no  histor\^ 
of  appendicular  disease,  this  type  was  present  in  62).  The  condition  is  confined 
to  no  age  period,  but  operative  aid  is  usually  sought  between  the  ages  of  thirty 
and  forty. 

Of  22  cases  operated  on  over  two  years  (some  of  the  earlier  ones  were  certainly 
not  suitable),  14  are  quite  well,  6  much  better,  i  unrelieved,  and  i  cannot  be 
traced. 

The  prognosis  in  the  cases  in  which,  in  addition  to  indigestion,  there  is  a  more 
or  less  constant  pain  in  the  right  iliac  fossa,  are  not  usually  cured  by  an  operation 
consisting  of  removal  of  the  appendix  alone. 

Many  are  relieved  by  aperients,  abdominal  exercises,  and  the  use  of  a  well- 
fitting  belt ;  others  in  addition  need  the  freeing  of  adhesions,  sometimes  ileo- 
colostomy  with  removal  of  the  ascending  colon. 

The  now  well-known  gastric  symptoms  associated  with  gall-stones  are  entirely 
relieved  by  operation. 

Renal  calculus  may  be  the  cause  of  symptoms  mimicking  gastric,  or  more 
often  duodenal,  ulcer.     These  entirely  disappear  after  operation. 

In  a  few  cases,  urinary  obstruction,  the  result  of  enlargement  of  the  prostate, 
is  associated  with  gastric  symptoms.     Operation  results  in  cure. 

Gastrojejunostomy  has  no  beneficial  effect  on  any  of  the  above  conditions. 
It  is  an  operation  that  should  be  carried  out  only  in  the  presence  of  definite 
organic  gastric  disease. 

Gastroptosls — The  fact  that  the  stomach  is  lower  than  normal  does  not 
constitute  disease.  The  symptoms  associated  with  this  condition  are  practically 
confined  to  the  female  sex.  It  must  be  remembered  it  is  not  the  stomach  only 
that  is  prolapsed,  nor  is  it  from  this  organ  that  symptoms  arise  in  the  majority 
of  cases.  The  patients  are  of  the  thin,  long-thorax  type,  and  the  beginning 
of  the  illness  is  usually  constipation.  This  later  becomes  associated  with 
irregular  gastric  symptoms,  flatulence,  pain  at  various  intervals  after  food,  and 
occasional  vomiting.  Neurasthenic  symptoms  often  supervene.  In  the  early 
days  of  gastric  surgery  many  of  these  cases  were  treated  by  gastrojejunostomy. 
Of  three  treated  by  myself,  all  developed  bilious  vomiting  necessitating  further 
operation. 

Rovsing^'  has  put  it  well  :  "  Gastrojejunostomy  ...  is  a  highly  injurious 
operation,  inasmuch  as  not  only  do  the  existing  symptoms  deteriorate  greatly, 
but  an  entirely  new  complex  of  symptoms  also  supervene,  nausea  and  gall- 
vomitings."  In  8  patients  he  had  to  operate  again,  separate  the  anastomosis, 
and  restore  the  parts  to  their  previous  condition. 

In  the  cases  comprised  under  this  heading  the  symptoms  are  by  no  means 
always  due  to  the  one  cause.  In  a  few,  gastric  symptoms  may  predominate, 
and  a  stenosis  of  the  pylorus  by  kinking,  or  a  chronic  obstruction  of  the 
duodenum  by  the  mesenteric  vessels,  be  discovered.  In  others  the  symptoms 
are  secondary  to  change  in  the  ileocaecal  region. 

Thorough  investigation  by  all  modern  methods  should  be  carried  out, 
including  x-xay  examination  after  bismuth  meals,  in  order  to  discover  if  there 
is  obstruction  in  any  part  of  the  canal. 

In    no    patient   should    operative    treatment    be    resorted    to    until    all    other 


496  INDEX     OF     PROGNOSIS 

measures  have  failed.  Rest  in  bed,  diet  and  massage,  followed  by  the  wearing 
of  an  abdominal  belt  and  strict  attention  to  the  bowels,  will  ameliorate  many. 

Operation  on  the  stomach  is  contra-indicated  except  in  those  rare  cases  in 
which  pyloric  stenosis  is  produced  by  kinking.  In  3  of  these  upon  whom  I 
performed  Finney's  gastroduodenostomy,  complete  cure  resulted.  In  2 
patients  in  whom  there  was  marked  obstruction  of  the  duodenum  at  the  point 
at  which  the  superior  mesenteric  vessels  crossed  it,  duodenojejunostomy  was 
followed  by  cure.  This  may  be  the  type  of  case  in  which  it  has  been  recorded 
that  gastrojejunostomy  gives  relief. 

Rovsing^*  is  an  advocate  of  operative  treatment  by  gastropexy,  combined, 
if  necessary,  with  colopexy  in  the  majority  of  cases.  His  results  in  163  cases 
are  as  follows  :  Cure,  50-6  per  cent  ;  great  improvement,  14-7  per  cent ;  im- 
provement, II  per  cent.  These  results  are  excellent.  All  the  cases  of  gastro- 
pexy, however,  that  have  come  under  my  personal  observation  were  no  better 
as  the  result  of  gastropexy. 

Infantile  Pyloric  Stenosis  {see  also  Pylorus,  Congenital  Stenosis  of). — If 
untreated  or  treated  late,  this  condition  is  almost  invariably  fatal.  Cautley 
and  Dent^^  stated  that  unless  operated  upon,  all  die  before  reaching  the  age 
of  four  months. 

Neurath^^  records  41  cases  in  infants  under  a  year,  all  of  whom  died  under 
medical  treatment.  On  the  other  hand,  Robert  Hutchison^'  records  20  cases 
medically  treated  with  18  recoveries,  and  Heubner^*  21  cases  with  19  recoveries. 

The  collected  death-rate  after  operation  is  over  40  per  cent,  although  indi- 
vidual surgeons  have  been  more  successful.  NicolP'  has  so  far  obtained  the 
best  results  from  his  pyloroplasty  combined  with  pyloric  stretching:  13  cases. 
II  recoveries. 

The  best  results  are  to  be  obtained  by  systematic  medical  treatment  as  soon 
as  symptoms  appear.  If,  in  spite  of  gastric  lavage  and  suitable  food,  weight 
is  steadily  lost  and  the  quantity  of  curd  returned  in  the  wash  shows  no  diminu- 
tion, surgical  treatment  should  be  adopted  without  delay.  This  should  consist, 
where  possible,  of  some  form  of  pyloroplasty. 

The  after-history  of  the  cases  treated  without  operation  is  not  fully  known. 
Maylard,*"  and  more  recently  Barling,*^  have  recorded  instances  in  young 
adults  in  which  the  condition  found  was  suggestive  of  infantile  stenosis.  The 
writer  has  had  two  cases  under  his  care  in  which  symptoms  of  dilatation  of 
the  stomach  in  early  adult  life  were  associated  with  a  difficulty  in  feeding  in 
infancy. 

Carcinoma  of  the  Stomach. — Unless  treated  by  operation,  life  is  rarely  pro- 
longed more  than  twelve  months  from  the  appearance  of  symptoms.  The 
results,  both  immediate  and  remote,  of  the  treatment  by  partial  gastrectomj- 
are  yearly  improving.  With  regard  to  the  immediate  mortality,  Deaver  and 
Ashhursf-  collected  747  cases  of  partial  gastrectomy  with  a  death-rate  of  25 
per  cent. 

The  most  successful  series  of  cases  are  those  published  by  W.  J.  Mayo.''^ 
The  immediate  mortality  in  the  last  100  cases  was  7  per  cent ;  in  the  last  50, 
4  per  cent.  In  863  operations  for  carcinoma  of  the  stomach,  resection  was 
carried  out  in  307  ;  36-6  per  cent  of  the  patients  are  alive  and  well  more  than 
three  years  after  operation,  22  per  cent  more  than  five  years. 

Feurer**  records  58  resections  with  a  death-rate  of  19  per  cent  ;  12  per  cent 
of  those  operated  upon  survived  more  than  four  years;    most  died  within  three. 

Weil,''^  from  Kiittner's  clinic,  reports  135  partial  gastrectomies  with  a  death- 
rate  of  22  per  cent ;  in  16  per  cent  of  those  operated  on,  life  was  prolonged  more 
than  three  years. 


STOMACH,     SURGICAL     AFFECTIONS     OF     THE  497 

In  140  from  Kocher's  clinic/^  20  per  cent  remained  well  over  four  years. 

Sherren  :  25  partial  gastrectomies,  3  deaths  from  operation  ;  9  are  still 
alive,  2  over  three  years,  i  over  two,  remainder  less  than  two.  Death  occurred 
from  recurrence,  the  earliest  three  months,  the  latest  thirty  months,  after 
operation. 

LangwUl,  reporting  on  cases  from  Caird's*''  clinic  :  In  54  excisions,  mortality 
49  per  cent,  8  alive  and  well  at  three,  ten,  eleven,  thirteen,  fourteen  months, 
five,  twelve,  and  fifteen  years. 

The  percentage  of  cases  suitable  for  radical  operation  must  vary  in  every 
clinic,  depending  as  it  does  upon  the  education  of  the  physician  to  modern 
surgical  doctrines  in  the  area  drained  by  the  hospital.  It  should  get  higher 
as  time  passes.     It  is  roughly,  at  the  present  time,  from  one-third  to  one-fifth. 

W.  J.  Mayo,  307  out  of  863. 

Caird,  59  out  of  189. 

Poncet,*^  Delore  and  Leriche,  40  out  of  137. 

Sherren,  25  out  of  112. 

Mayo  sums  up  the  present  outlook  as  follows  :  "  A  patient  with  a  cancer 
of  the  stomach  which  is  sufficiently  localized  to  be  removed  radically  has  better 
than  a  90  per  cent  chance  to  recover  from  the  operation,  better  than  a  36  per 
cent  chance  of  a  three-year  cure,  and  at  least  a  25  per  cent  chance  of  a  five- 
year  cure." 

When  recurrence  takes  place,  the  average  duration  of  life  is  eighteen  months, 
but  the  quality  of  that  hfe  is  much  better  than  if  gastrojejunostomy  alone  had 
been  done.  Comfort  is  usually  given  until  shortly  before  death,  which  does 
not  generally  occur  from  recurrence  of  growth  in  the  portion  of  stomach  which 
remains.  Recurrence  is  rare  after  two  years,  and  if  life  is  prolonged  beyond 
four  years  is  very  unusual. 

Even  the  collected  cases  of  Paterson,  in  1906,  gave  a  percentage  of  15  per 
cent  out  of  79  alive  and  well  more  than  five  years  after  operation,  and  38  per 
cent  well  three  years  after. 

It  is  obvious  that  the  outlook  in  carcinoma  of  the  stomach,  if  operated  upon 
early,  is  extremely  good.  But  it  is  necessary  to  refer  suspicious  cases  to  the 
surgeon  at  once.  The  death-rate  of  simple  exploration  is  small ;  among  49 
of  my  own  cases  2  died  within  forty-eight  hours.  As  a  rule,  death  occurs  within 
three  months,  and  occasionally  a  period  of  improvement  occurs  and  all  symptoms 
disappear.  Five  such  cases  have  been  under  my  care.  In  one  the  symptoms 
remained  in  abeyance  for  eighteen  months,  in  another  for  fourteen. 

Total  Gastrectomy. — It  is  rarely  that  this  operation  is  indicated  in  cases 
of  carcinoma  of  the  stomach  of  the  usual  type.  It  is  necessary  in  rare  cases 
in  which  the  disease  arises  in  the  fundus  or  the  small  group  of  cases  of  plastic 
linitis — leather-bottle  stomach  of  the  malignant  type.  The  immediate  death- 
rate  is  higher  than  that  of  partial  gastrectomy. 

Mayo,  in  7  cases  in  which  an  almost  complete  operation  was  carried  out, 
had  3  operative  deaths,  and  no  patient  survived  two  years. 

Carcinoma  of  Cardiac  End. — At  the  present  time,  radical  treatment  of 
malignant  disease  in  this  situation  is  not  established  upon  a  successful  technique. 
Several  cases,  however,  have  been  recorded  in  which  the  growth  was  removed 
and  oesophago-gastrostomy  done.  Death  occurred  in  all  within  a  few  days. 
Zaaijer^^  has  recently  recorded  a.  successful  case  in  which,  after  the  performance 
of  gastrostomy,  the  growth  was  removed  in  two  stages. 

Palliative  Operations  in  Carcinoma  of  Stomach.  —  Gastrojejunostomy  is  of 
striking  service  in  the  relief  of  symptoms  when  the  growth  is  causing  pyloric 
obstruction,    and    in    the    rare    cases    of    malignant    hour-glass    stomach.     Its 

32 


498  INDEX     OF     PROGNOSIS 

performance  should  be  limited  to  these,  for  it  affords  little  or  no  relief  when 
the  growth  is  not  causing  mechanical  obstruction. 

The  immediate  death-rate  is  much  higher  than  when  the  operation  is  carried 
out  for  simple  conditions.     Thus  : — 

Poncet,  Delore  and  Leriche  :    87  cases,  33  per  cent. 
Mo^'nihan,  35  cases  :  14  per  cent. 
Sherren,  36  cases :    14  per  cent. 

The  average  duration  of  life  is  about  six  months.  The  longest  in  my  series 
was  two  years,  with  twenty-two  months'  absolute  comfort,  another  fifteen  months, 
2  over  a  year. 

The  relief  afforded  is  striking,  and  the  operation  certainly  one  to  be  recom- 
mended.    The  patients  are  usually  able  to  resume  ordinary  life. 

Gastrostomy  and  Jejunostomy. — These  operations  do  not  stand  on  the  same 
plane  with  gastrojejunostomy.  As  a  routine  procedure  in  inoperable  carcinoma 
of  the  stomach,  they  are  inadvisable.  It  is  one  of  the  operations  that  must 
be  left  to  the  choice  of  the  patient,  remembering  that  the  quality  of  life  is 
not  good,  and  that  the  discomfort  of  artificial  feeding  is  very  great  to  some 
individuals. 

The  immediate  death-rate  of  gastrostomy  is  low.  As  a  rule,  life  is  not  pro- 
longed more  than  six  months,  usually  less. 

Jejunostomy  in  127  cases  collected  by  Billon^"  gave  a  death-rate  of  29  per 
cent,  and  the  majority  lived  less  than  two  months. 

Sarcoma  of  Stomach. — There  are  clinically  two  types  of  this  disease :  one 
in  which  the  tumour  is  often  round-celled  and  the  symptoms  resemble  those 
of  carcinoma ;  the  other  in  which  a  polypoid  tumour  is  present,  springing  usually 
from  the  greater  curvature.  The  average  duration  of  life  is  about  fifteen 
months  in  the  round-celled,  twenty-eight  months  in  the  polypoid. 

Gosset^"^  has  recently  collected  61  cases  of  sarcoma  of  stomach  treated  by 
operation.  Of  these,  29  were  of  the  polypoid  type,  10  deaths.  The  longest 
survival  was  seven  and  a  half  years.  Twenty-two  were  of  the  first  type;  13 
were  resected,  with  five  deaths,  three  patients  living  one,  four,  and  six  years 
after  operation. 

The  writer  has  in  addition  treated  by  resection  2  cases  of  the  polypoid  type. 
In  I  already  recorded,  ^^  recurrence  took  place  within  three  months.  The 
other,  a  boy  of  fourteen,  remains  well  four  months  later. 

Plastic  Linitis  {Cirrhosis  of  stomach  :  fibromatosis  of  stomach  :  Alexis  Thomson). — 
This  disease  is  characterized  by  a  diffuse  fibrous  thickening  of  the  stomach 
involving  the  submucous  coat  and  starting  usually  in  the  pyloric  region.  The 
condition  may  be  either  simple  or  malignant.  The  relative  frequency  of  the 
two  types  is  difficult  to  estimate,  for  it  may  be  impossible,  even  after  micro- 
scopical examination  of  the  stomach,  to  say  to  which  group  it  belongs.  Sections 
of  the  stomach  may  appear  simple,  yet  secondary  deposits  may  be  present 
in  the  Uver.     Unrelieved  by  surgery  the  disease  is  uniformly  fatal. 

Lyle,^*  in  an  exhaustive  paper  bringing  the  subject  up  to  date,  found  in  43 
cases  the  average  duration  of  life  was  forty-nine  months  (shortest  three  months, 
longest  twenty  years).  In  37  of  the  so-called  malignant  type,  the  average 
was  23-9  months. 

He  records  25  cases  treated  by  operation  :  3  total  gastrectomy,  i  well  four 
years  later:  13  partial  gastrectomies;  details  of  many  of  these  are  lacking, 
but  life  was  prolonged  beyond  two  years  in  at  least  3  cases  ;  8  gastro-enterostomy  : 
of  these  there  were  4  operative  deaths.  One  died  four  years  after  operation, 
cause  not  known.  Others  ahve  and  well  eight  years,  four,  and  three  and  a  half 
years   after    operation.     There  is,    in    addition,    Moynihan's    case    of   complete 


STOMATITIS  499 


gastrectomy^^  for  the  malignant  type  of  the  disease  in  which  death  occurred 
four  years  later. 

Jejunostomy :  4  cases:  3  died  within  a  few  days,  i  is  alive  and  well  five  years 
later. 

Five  cases  have  been  operated  on  by  the  author.  To  the  naked  eye,  all 
were  typical  of  this  condition.  3  were  certainly  malignant,  although  in  one 
with  secondary  deposits  in  the  liver,  sections  of  the  stomach  wall  revealed 
no  trace  of  malignancy.  Of  these  cases,  4  were  treated  by  gastrojejunostomy: 
I  is  alive  and  well  two  years  later,  and  i  ten  months  later.  One  lived  in  com- 
fort  for  a  year  and  died  in  twenty  months,  i  died  five  months  later. 

In  I  patient  in  whom  I  performed  jejunostomy,  life  was  prolonged  in  reason- 
able comfort  for  four  months.  Gastrectomy,  complete  or  partial,  failing,  this 
gastrojejunostomy  allows  of  prolongation  of  comfortable  life  with  a  prospect 
of  cure. 

References  — ^Brit.  Med.  Jour.  1912,  ii,  936  ;  ^Med.-Chir.  Trans.  1902,  xxvi,  86  ; 
^Habershon's  Diseases  of  Stomach,  214  ;  *Jour.  Amer.  Med.  Assoc.  1906,  xlvii,  14  ; 
^Atner.  Jour.  Med.  Sci.  1899,  cxviii.  167  ;  ^Amer.  Jour.  Med.  Sci.  1909,  Dec.  ;  ''Beit- 
zur  klin.  Chir,  1911,  Ixxvi,  638;  ^Rev.  de  Chir.  1904,  xxx,  79;  ^Deut.  Zeit.  f.  Chirurg. 
1903,  Ixix.  s.  178  ;  ^^Edin.  Med.  Jour.  1906,  Aug.  and  Sept.  ;  ^^Med.  Press  and  Circ. 
1903,  321  ;  ^^Med.-Chir.  Trans,  xc,  218  ;  ^'^Med.  Soc.  Trans.  1902,  xxvi.  86  ;  ^^Ann. 
Surg.  1911,  313  ;  ^^Med.-Chir.  Trans,  xc,  410  ;  ^^Beit.  zur  klin.  Chir.  Ixxvi,  1911, 
305  et  seq.  ;  ^'i;.  Langenbeck's  Archiv.  1909,  xc,  heft  i  ;  ^^Deut.  Zeit.  f.  Chir.  Bd.  116, 
Festschrift,  1912,  183-226  ;  ^^v.  Langenbeck' s  Archiv.  1909,  xc,  heft  i  ;  ^"Brit.  Med. 
Jour.  1912,  ii,  864  ;  ^^Zentr.  f.  Chir.  Beilage,  1910,  No.  31  ;  ^^Rev.  de  Chir.  1908, 
269,  403,  761  ;  ^Deut.  Zeit.  f.  Chir.  1903,  Ixix  ^*Mitt.  a.  d.  Grenzgeb.  d.  Med. 
u.  Chir.  Bd.  xxv.  heft  3  ;  ^^Zentr.  f.  Chir.  Beilage,  1913,  No.  28,  6r  ;  ^^Duodenal 
Ulcer,  2nd  ed.  312  ;  ^''Med.  Press  and  Circ.  1909,  347  ;  ^^Brit.  Med.  Jour.  1909,  ii,  946; 
^^Brit.  Med.  Jour.  1912,  ii,  1389  :  ^^Arch.  f.  klin.  Chir.  1910,  xci,  380  ;  ^^Surg.  Gyn. 
and  Obst.  1910,  227;  ^-Clin.  Jour.  1913,  Sept.  24,  xiv  ;  ^^Ann.  Stirg.  igi^,  i;  ^*Loc. 
cit.  ;  ^^Med.-Chir.  Trans.  1903,  Ixxxvi,  471  ;  Brit.  Med.  Jour.  1906,  ii,  939  ;  ^^Cenir. 
d.  Grenz.  d.  Med.  u.  Chir.  1899,  ii,  696  ;  ^''Brit.  Med.  Jour.  1910,  ii,  1021  ;  ^^Therap. 
der  Gegenwart,  1906,  Oct.  ;  ^^Glasg.  Med.  Jour.  1906,  Ixv,  253  ;  Tract.  1910,  ii,  659  ; 
*'^Trans.  Clin.  Soc.  xxxvii.  63  ;  ^^Lancet,  1913,  i,  231  ;  ^^Surgery  of  the  Upper  Abdomen, 
vol.  i.  ;  *^Surg.  Gyn.  and  Obst.  x,  10,  No.  2,  115  ;  **Deut.  Zeit.  f.  Chir.  Bd.  116,  Fest- 
schrift, 1912,  69  ;  ^^Berl.  klin.  Woch.  1913,  Mar.  3  ;  *'^Mitt.  a.  d.  Grenzgeb.  d.  med.  u.  Chir. 
Bd.  XX,  heft  5  ;  ^''Edin.  Med.  Jour,  x,  222  ;  *^Gaz.  4es  Hopitaux,  1909,  35  ;  ^^Beiir. 
z.  klin.  Chir.  1913,  Ixxxiii,  419  ;  ^"Anns.  interne  de  Chirur.  gastro-intest.  1909,  Nos.  2,  3  ; 
"^Presse  Med.  1912,  Mar.  16  ;  ^^Brit.  Med.  Jour.  1911,  ii.  593  ;  ^^Ann.  Surg.  1911,  625  ; 
'^Lancet,  1911,  Aug.  12.  James  Sherren. 

STOMATITIS  [see  also  Cancrum  Oris  and  Scurvy). — Most  of  the  conditions 
included  under  this  title  are,  of  course,  transient  and  of  no  great  importance. 
Simple  catarrhal  stomatitis,  thrush,  the  aphthous  variety,  and  the   chronic 

form  sometimes  met  with  in  adults,  very  seldom  do  any  harm,  and  yield  in  a 
week  or  two  to  treatment,  such  as  removal  of  the  cause  and  the  use  of  mouth- 
washes. In  weakly  infants,  however,  infection  with  the  Oidium  albicans  is 
sometimes  a  serious  matter,  and  may  turn  the  scale  against  the  child  by  leading 
to  semi-starvation  and  septic  absorption. 

Mercurial  Stomatitis  very  seldom  lasts  long,  or  does  any  harm,  if  it  is  recognized 
and  the  drug  v/ithdrawn  ;  but  if  this  is  long  delayed,  the  patient's  mouth  may  get 
into  a  dreadful  state,  and  in  rare  cases  in  the  past  there  has  been  a  fatal  issue, 
so  that  at  one  time  it  was  a  capital  offence  in  France  to  prescribe  mercury  as  a 
medicine. 

Ulcerative  Stomatitis  is  also  a  grave  disease  in  weakly  children.  Usually  it 
yields  to  treatment  with  potassium  chlorate  and  other  similar  remedies,  but 
when  the  mouth  is  very  foul,  with  gangrenous  areas  and  white  or  grey  sloughy 
ulcers,  there  is  considerable  danger  to  life.  The  writer  has  seen  a  case  in  a  boy 
of  twelve,  beginning  as  an  ulcerous  condition  of  the  gums,  and  steadily  advancing 


500  INDEX     OF     PROGNOSIS 

all  over  the  alveolar  borders,  but,  unlike  cancrum  oris,  sparing  the  cheeks. 
Mercurialism  and  scurvy  were  excluded,  and  there  had  been  no  previous  illness. 
In  spite  ot  cauterization  and  other  energetic  treatment  the  boy  got  worse,  and 
an  attempt  was  made  to  burn  away  the  foul  areas  ;  but  he  was  in  extremis  and 
died  under  the  anaesthetic.  a.  Rendle  Short. 

STRICTURE  OF  (ESOPHAGUS. — (See  (Esophagus,   Stricture  of.) 

STRICTURE  OF  URETHRA.— (See  Urethral  Stricture.) 

STROKES. — The  term  stroke,  or  ictus,  is  applied  to  a  spontaneous  cerebral 
attack  due  to  some  form  of  vascular  disease,  whether  obstruction  or  rupture  of 
a  cerebral  vessel.  In  a  severe  case,  the  patient  at  once  becomes  comatose  and 
hemiplegic  ;    in  other  cases,  hemiplegia  occurs  without  loss  of  consciousness. 

Prognosis  as  to  Life. — The  prognosis  of  recent  hemiplegia  depends  upon  the 
nature,  extent,  and  situation  of  the  cerebral  lesion. 

The  Nature  of  the  Lesion. — With  regard  to  this,  we  have  to  determine  whether 
the  case  is  one  of  arterial  obstruction  from  embolism,  or  from  thrombosis,  or 
whether  it  is  one  of  hsemorrhage  from  a  ruptured  vessel.  The  rapidity  of 
onset  of  the  symptoms  is  of  diagnostic  significance. 

Embolism,  as  a  rule,  occurs  suddenly,  the  arterial  obstruction  being  due 
to  a  plug  of  fibrin  carried  in  the  blood-stream  from  the  left  side  of  the  heart,  or 
from  the  roughened  wall  of  an  aortic  aneurysm.  Consciousness  may,  or  may  not, 
be  lost  in  cerebral  embolism  ;  in  most  cases  it  is  lost,  and  the  cases  where  it  is  not 
affected  are  generally  those  in  which  the  obstructed  artery  is  a  small  one,  and 
where  the  paralysis  is  of  correspondingly  less  extent. 

Cerebral  thrombosis  from  disease  of  the  vessel-wall,  syphilitic  or  otherwise, 
or  from  morbid  coagulability  of  the  blood  (e.g.,  during  pregnancy  or  the  puer- 
perium),  is  usually  rapid  in  onset,  though  less  so  than  in  embolism.  In  syphilitic 
cases,  it  is  often  preceded  for  days  by  headache  or  mental  confusion,  or  there  may 
be  pre-hemiplegic  convulsions,  sometimes  unilateral.  Unconsciousness  deepening 
into  coma  may  be  present,  as  in  embolism,  if  the  thrombotic  lesion  be  a  large  one. 

Cerebral  haemorrhage,  froin  rupture  of  a  diseased  artery  or  a  miliary 
aneurysm,  is  usually  associated  with  conditions  of  high  blood-pressure,  whether 
from  general  arteriosclerosis,  as  in  the  gouty  diathesis  or  in  old  age,  or  from 
chronic  renal  disease.  In  arteriosclerotic  cases  the  actual  attack  is  often 
precipitated  by  excitement,  emotion,  or  physical  exertion,  and  a  particularly 
common  time  of  onset  is  during  straining  at  stool.  Other  cases  occur  in  morbid 
blood  conditions  without  vascular  disease,  as  in  the  bleeding  diseases  (haemo- 
philia, purpura,  leukaemia,  scorbutus,  pernicious  anaemia)  ;  also  in  certain 
cases  of  whooping-cough,  where  the  heemorrhage  is  usually  due  to  rupture  of  a 
cortical  vein  during  a  paroxysm  of  coughing. 

Other  things  being  equal — i.e.,  in  lesions  of  equal  size  and  similar  situation, — the 
prognosis  as  to  life  is  more  serious  in  haemorrhage  than  in  thrombosis,  since  it  is 
easier  to  stimulate  the  circulation  in  cases  of  thrombosis,  than  to  depress  it  in 
cases  of  haemorrhage.  Embolic  cases,  as  a  rule,  have  a  good  prognosis,  except 
when  due  to  ulcerative  endocarditis,  in  which  the  infective  nature  of  the  embolus 
renders  the  prospects  hopeless. 

The  Extent  and  Situation  of  the  Lesion. — The  size  of  the  lesion  is  an  important 
element  in  prognosis.  The  larger  the  area  of  brain  tissue  that  is  destroyed,  the 
graver  the  prognosis.  This  statement,  however,  must  be  qualified  by  the  further 
consideration  of  the  situation  of  the  lesion :  since  it  is  obvious  that  a  relatively 
small  lesion  in  the  medulla  or  pons  may  be  rapidly  fatal,  whereas  in  the  corona 
radiata  it  may  produce  comparatively  slight  symptoms. 


STROKES  501 

Coma. — The  occurrence  of  coma,  and  its  duration,  have  an  important  prognostic 
value.  Coma  is  one  of  the  signs  of  increased  intracranial  pressure,  and  the 
larger  the  haemorrhage,  as  a  rule,  the  deeper  the  coma.  (There  is  an  important 
exception  to  this  rule  in  the  case  of  hsemorrhages  in  the  region  of  the  medullary- 
vital  centres,  where  a  small  lesion  may  prove  rapidly  fatal.)  If  the  coma  be 
slight  in  degree,  or  if  it  be  short  in  duration,  even  if  deep,  we  give  a  favourable 
prognosis  as  regards  life.  Where  it  is  profound  and  early  in  onset,  a  very  guarded 
prognosis  should  be  given ;  and  where  it  persists  for  over  twelve  hours  without 
any  diminution  in  intensity,  the  prospects  of  survival  are  small.  In  cases  which 
are  likely  to  recover,  signs  of  consciousness  usually  begin  to  return  in  two  or 
three  hours.  Cases  which  remain  deeply  comatose  for  twenty-four  hours  rarely 
survive.  If  a  patient  with  initial  hemiplegia  and  coma  returns  rapidly  to 
consciousness,  and  then  suddenly  relapses  into  coma  again,  this  suggests  the 
presence  of  a  haemorrhage  into  the  ventricles,  and  the  outlook  is  practically 
hopeless. 

Temperature. — A  study  of  the  patient's  temperature  is  also  of  importance. 
A  normal  temperature  is  a  good  sign.  In  cerebral  haemorrhage  there  is  often  an 
initial  fall,  followed  by  a  moderate  pyrexia.  The  more  severe  the  lesion,  the 
more  profound  are  the  temperature  reactions.  In  a  bad  case,  the  temperature 
may  fall  to  96°  F.  or  even  94-4°  F.,  and  the  patient  may  die  before  the  occurrence 
of  any  pyrexial  reaction  ;  generally  the  initial  fall  is  followed  by  a  rise.  The 
higher  the  temperature,  the  graver  the  prognosis  ;  and  if  hyperpyrexia  of  105°  to 
108°  F.  occurs,  the  outlook  is  hopeless. 

The  Cardio-vascular  signs  should  also  be  carefully  observed.  If  the  pulse 
becomes  abnormally  slow  or  quick,  or  if  its  rhythm  becomes  irregular,  the 
prognosis  is  unfavourable.  A  progressive  rise  of  blood-pressure  is  another 
unfavourable  sign. 

Deepening  Stertor  of  breathing,  and  the  occurrence  of  a  Cheyne-Stokes  type  oj 
respiration,  are  also  signs  of  deepening  coma. 

Albuminuria  or  Glycosuria,  if  present,  increase  the  likelihood  of  a  fatal  issue, 
since  these  conditions  indicate  the  activity  of  other  factors  in  addition  to  the 
mechanical  one  of  the  vascular  intracranial  lesion. 

Convulsions,  when  occurring  in  a  comatose  and  hemiplegic  patient,  are  always 
of  grave  import  ;  they  indicate  cortical  irritation,  either  from  a  meningeal 
haemorrhage,  or  from  sudden  increase  in  the  intracranial  pressure,  as  when  a 
haemorrhage  bursts  into  the  ventricles  or  into  the  substance  of  the  pons. 

Prognosis  as  to  Recovery. — The  foregoing  signs  concern  themselves  mainly 
with  the  immediate  prognosis  as  to  life.  Should,  however,  the  patient  survive 
the  particular  attack,  the  further  question  arises  as  to  how  far  his  hemiplegic 
symptoms  are  likely  to  clear  up.  The  answer  to  this  question  depends  upon  the 
size  and  situation  of  the  lesion.  A  small  lesion  which  does  not  interrupt  the 
pyramidal  iibres,  but  merely  compresses  them,  may  produce  signs  and  symptoms 
which  ultimately  clear  up  completely.  In  other  cases,  where  a  certain  proportion 
of  pyramidal  fibres  are  destroyed,  whilst  others  are  merely  temporarily  com- 
pressed, as  in  a  small  cortical  or  subcortical  lesion,  the  original  hemiplegia  may 
recede  to  a  monoplegia  as  the  clot  shrinks  by  absorption  and  the  unsevered 
fibres  recover  their  function.  It  is  difiicult  to  lay  down  definite  rules  for  guidance 
on  this  point,  but  it  is  generally  recognized  that  if  any  material  improvement 
in  the  hemiplegic  symptoms  is  likely  to  occur,  some  signs  of  return  of  power  will 
be  found  within  a  week  or  ten  days.  Improvement,  as  a  rule,  begins  in  the 
lower  limb  before  the  upper.  Trousseau  stated  that  when  the  arm  begins  to 
recover  before  the  leg,  the  ultimate  result  is  less  satisfactory ;  but  this  dictum 
is  not  absolute. 


502  INDEX     OF     PROGNOSIS 

The  occurrence  of  early  rigidity  of  the  hemiplegic  Umbs— i.e.,  within  the  first 
week — is  unfavourable  as  regards  recovery  of  motor  power.  Rigidity  of  later 
onset,  with  increased  deep  reflexes,  indicates  permanent  degeneration  of  the 
pyramidal  fibres. 

The  appearance  of  an  acute  sloughing  bedsore  on  the  hemiplegic  side,  whether 
over  the  sacrum,  great  trochanter,  outer  malleolus,  or  heel,  in  a  patient  who  is 
being  assiduously  nursed,  and  whose  skin  is  being  watched  and  protected  (as 
that  of  all  paralyzed  patients  should  be),  is  of  grave  import, — the  decubitus 
ominosus  of  Charcot.  Sometimes  it  occurs  within  a  few  days  after  the  onset 
of  paralysis,  and  is  resistant  to  treatment ;  it  occurs  chiefly  in  cases  of  profound 
hemiplegia  in  which  there  is  a  degree  of  mental  obtusion.  Purves  Stewart. 

SUBPHRENIC  ABSCESS. — Under  this  heading  we  include  abscesses  beneath 
the  diaphragm  of  varying  origin,  the  majority  following  perforation  of  a  gastric 
or  duodenal  ulcer,  or  of  the  vermiform  appendix.  Tropical  abscess  of  the  liver, 
spinal  caries,  and  a  number  of  other  primary  causes  lead  to  subphrenic  abscess, 
but  much  less  commonly  than  those  first  mentioned.  We  are  greatly  indebted 
to  the  late  Mr.  Harold  Barnard  for  his  classical  study  of  the  subject,  based 
upon  the  records  of  76  cases  at  the  London  Hospital. 

As  a  complication  of  appendicitis,  this  disease  is  not  uncommon,  and  unless 
early  recognized  and  energetically  treated,  it  is  almost  a  death-warrant.  The 
usual  course  of  events  is  that  the  patient  is  operated  on  about  the  third  or  fourth 
day  or  later,  and  a  fairly  widely-diffused  peritonitis  is  found  ;  the  appendix 
is  removed  and  a  drainage-tube  put  in,  but  the  temperature  remains  high,  or  falls 
for  a  few  days  and  then  rises  again,  and  the  patient  wastes,  and  may  vomit  or 
have  rigors.  Careful  examination  may  reveal  a  resistant  or  tender  area  in  the 
right  upper  abdomen,  or  there  may  be  dullness  at  the  base  of  the  right  lung. 

Having  defined  what  class  of  cases  enters  into  the  argument,  we  many  now 
inquire  into  the  prognosis. 

Barnard  reported  on  76  cases.     Of  these  : — 

12  cases  not  operated  on  ;    0  lived,         12  died    =  100    percent. 

64  cases  operated  on  ;         40  lived,         24  died    =     37'5percent. 

Barnard's  own,    21  cases  operated  on ;         17  lis'ed,  4  died    =     19    per  cent. 

Of  the  36  fatal  cases,  24  are  classed  as  avoidable,  that  is,  they  either  passed 
undiagnosed,  or  the  operation  did  not  secure  proper  drainage,  as  for  instance 
when  an  anterior  drain  was  used  in  cases  demanding  a  posterior. 

In  23  out  of  76  cases,  the  abscess  ruptured  spontaneously  (into  bronchus  or 
pleura  9  times,  into  stomach  8  times). 

The  operation  mortality  given  by  various  German  authors  agrees  closely  with 
the  figures  just  quoted. 

In  estimating  the  prognosis  in  any  particular  instance,  it  must  be  borne  in 
mind  that  when  the  stomach  is  the  primary  locus  of  the  disease  the  outlook  is 
graver  than  in  appendicitis  cases  (Keen).  Rigors  are  an  unfavourable  sign, 
6  out  of  10  dying  (Barnard),  and  so  is  jaundice,  because  these  may  indicate 
portal  pylephlebitis.  Early  operation  gives  much  better  results,  of  course,  than 
late  ;    according  to  Sachs  : — 

Operation  within  3  weeks  ;   1.5  per  cent  died. 
Operation    after    3  weeks  ;   50  per  cent  died. 

Posterior  drainage  gives  better  results  than  anterior,  as  is  shown  by  Barnard's 
table. 

26  posterior  operations  ;    7  died  =  27     per  cent. 

43  anterior    operations ;  17  died  =  3'.)"5  per  cent. 

4  lateral    operations  ;     3  died  =  75    per  cent. 


SYPHILIS 


503 


We  may  conclude,  therefore,  that  in  practice  about  one-third  of  the  cases  die, 
but  that  careful  diagnosis  and  prompt  efficient  drainage  would  probably  save 
four  out  of  five. 

Reference. — Barnard,  Brit.  Med.  Jour.  191 


371,  429- 


A.  Rendle  Short. 


SYPHILIS. 

I.  Prospect  of  Immediate  Cure  in  the  Primary  Stage. — Excision  of  the 
primary  chancre  was  claimed  by  Auspitz  to  have  cured  the  disease  in  25  per 
cent  of  33  cases  so  treated,  but  in  the  experience  of  other  observers  this  plan 
was  not  attended  with  equal  success.  It  is  possible  that  the  disease  may  be 
considerably  modified,  and  even  aborted,  by  this  treatment,  if  supplemented  by 
injections  of  salvarsan.  The  size  and  situation  of  the  initial  lesion  seldom  admit 
of  this  procedure,  owing  to  the  mutilation  which  would  be  entailed  ;  but  there  is 
one  class  of  chancre  for  which  this  treatment  is  appropriate,  viz.,  when  the  sore 
is  situated  at  the  preputial  orifice  and  can  be  completely  removed  by  circum- 
cision, the  inguinal  glands  being  also  excised  at  the  same  time. 

The  earlier  the  constitutional  treatment  of  syphilis  is  commenced,  the  better 
is  the  ultimate  prognosis,  and  the  best  test  of  the  efficacy  of  treatment  is  the 
absence  of  subsequent  relapses.  The  advantage  of  commencing  treatment  in 
the  primary  stage  is  well  exemplified  by  statistics  on  the  subject  recently 
brought  forward  by  Colonel  Gibbard  and  Major  Harrison,  R.A.M.C,  as  shown 
in  the  following  tables  : — 

Table  I. 
The  Advantage  of  Commencing  Treatment  in  the  Primary  Stage. 

Number  of  relapses  which  occurred  when  salvarsan  treatment  was  commenced  in  the 
primary  and  secondary  stage  respectively. 


Period  of 

observation  Irom 

date  of 

last  injection 

Stat-'e  of  disease 

at  which 

treatment 

commenced 

Total 
cases 

Relapses 

Percentages 

of  total 
clinical  and 

Clinical 

Wassermann,  without 
clinical  symptoms 

Actuals 

Percentages 

Actuals 

Percentages 

reactions 

Si.x  months   •[ 

Twelve           j 
months  ( 

Primary 
Secondary 
Primary 
Secondary 

92 
174 

70 
130 

5 

7 

10 

.5-4 
4 

4-2 
7-6 

6 
31 

5 
34 

6-5 
17-8 

7-1 
26-1 

119 
21-8 
114 
33-8 

From  this  table  it  will  be  seen  that  the  prognosis  as  regards  relapses  is  far 
more  favourable  when  treatment  is  commenced  in  the  primary  stage  than  when 
it  is  deferred  to  the  secondary  period. 

2.  Comparative  Value  of  Salvarsan,  Neosalvarsan,  Mercury,  and  the  Iodides. — 
It  is  a  matter  of  some  difficulty  at  the  present  moment  to  compare  the  relative 
merits  of  salvarsan  and  neosalvarsan  with  those  of  mercury.  Ardent  advocates 
of  the  two  former  preparations,  relying  on  the  Wassermann  reaction,  claim  that 
by  their  agency  alone  syphilis  can  be  cured,  and  they  further  claim  that  mercury 
by  itself  has  never  cured  a  case  of  syphilis.  The  salvarsan  treatment  has 
not  been  in  existence  for  a  sufficient  period  to  enable  one  to  assert  that 
any  case  of  syphilis  has  ever  been  cured  by  its  agency  alone,  and  further  experi- 
ence is  required  before  one  is  justified  in  stating  that  salvarsan  is  capable  of 
preventing  the  manifestations  of  tertiary  syphilis  and  of  nerve  syphilis.  Before 
its  advent,  innumerable  cases  of  syphilis,  treated  by  mercury  alone,  were 
apparently  cured  ;    the  patients  married  and  produced  healthy  families,   and 


504 


INDEX     OF     PROGNOSIS 


moreover,  their  Wassermann  reaction,  taken  since  the  discovery  of  that  valuable 
test,  has  been  rendered  negative  by  mercurial  treatment  alone. 

Certainly  no  ca^e  of  syphilis  has  ever  been  cured  by  the  iodides  alone,  and  they 
may  be  regarded  as  only  of  value  in  relieving  certain  manifestations  of  the 
disease,  such  as  ulcers  of  mucous  membranes,  and  in  promoting  the  absorption 
of  the  products  of  syphihtic  inflammation,  as  in  periostitis,  etc.,  but  as  curative 
agents  they  may  be  disregarded  and  dismissed  from  consideration.  It  is  futile 
to  pit  two  such  valuable  remedies  as  salvarsan  and  mercury  one  against  the 
other,  for  there  is  much  to  be  said  for  or  against  either  of  these  t^vo  modes  of 
treatment ;  but  it  appears  now  to  be  generally  accepted  that  the  best  means  of 
eradicating  the  disease  is  by  a  judicious  combination  of  the  two  methods,  and, 
given  a  healthy  subject  thus  treated,  one  may  safely  give  a  most  hopeful  prognosis 
as  regards  cure,  as  regards  the  impossibility  of  transmitting  disease  to  the 
offspring,  and  as  regards  immunity  from  nerve  syphihs.  In  confirmation  of  this 
statement,  reference  may  again  be  made  to  the  valuable  statistics  recently 
published  by  Colonel  Gibbard  and  Major  Harrison,  in  which  the  relative  merits  of 
salvarsan  alone  and  in  combination  with  calomel  cream  and  mercurial  cream, 
are  compared.  From  these  figures  it  wih  be  seen  that  the  percentage  of  relapses 
was  far  less  in  cases  treated  by  two  injections  of  salvarsan  and  nine  of  mercurial 
cream  (Hg,  gr.  i )  than  in  those  treated  by  salvarsan  alone,  or  by  the  combination 
of  salvarsan  and  calomel  cream  (HgoCU,  gr.f). 

Table   II. 
Comparison  of  Different   Methods  of  using  Salvarsan. 


Number  of  relapses  which  occurred  in  previously  untreated  cases  of  syphilis. 

Relapses 

Period  of 

Percentages 
of  total 

Total 

date  of 

cases 

Clinical 

clinical  symptoms 

clinical  and 

"Zrts<"  injection 

Actuals 

Percentages 

Actuals 

Percentages 

relapses 

/ 

Salvarsan  onlv 

71 

5 

7 

12 

16-9 

239 

Three  salvarsan  and 

Six  months    ■ 

four  calomel 
Two    salvarsan   and 

63 

2 

3-1 

10 

15-8 

18-9 

nme  mercury 

132 

5 

3-7 

15 

11-3 

15-1 

j  Sal\'arsan  onlv 

48 

7 

14-5 

9 

18-7 

33-3 

„     ,                   ;  Three  salvarsan  and 

Twelve            J 

four  calomel 

52 

1 

1-9 

12 

23 

25 

months  1 

Two    salvarsan   and 

nine  mercury 

100 

5 

0 

18 

IS 

23 

Note. — From  December  i2th  to  April  13th,  of  91  cases  treated  with  three  five-weekly 
injections  of  o-6  gram  salvarsan  and  ten  weekly  injections  of  mercury,  none  have 
so  far  relapsed  cUnicaUj'  or  given  a  positive  Wassermann  reaction. 

In  summarizing  the  results  of  their  experience.  Colonel  Gibbard  and  ^Major 
Harrsion  state  that  "  even  if  no  improvement  is  made  in  the  method  of  using 
salvarsan  which  has  given  the  best  results  in  our  hands,  its  routine  use  for  the 
treatment  of  syphilis  in  the  army  is  likely  to  effect  an  annual  saving  of  70,000 
to  80,000  hospital  days,  an  economy  equivalent  to  the  cost  of  keeping  a  battalion 
of  infantry  in  hospital  for  three  months." 

The  combination  of  salvarsan  and  mercury  is  immeasurably  superior  to  the 
treatment  of  mercury  alone,  as  will  be  seen  on  reference  to  the  following  figures, 
also  supplied  by  Colonel  Gibbard  and  Major  Harrison. 


SYPHILIS 


505 


Table  III. 
Comparison  between  Salvarsan  and   exclusively  Mercurial  Treatment. 

Total  relapses  and  average  time  lost  by  each  soldier  in  hospital,  and  attending  as  an 
out-patient,  under  treatment  with  mercury  and  with  mercury  and  salvarsan  respectively 
during  the  first  year. 


Total 
cases 

Average 
number  of 
days  in 
hospital 
on  first 
admission 

Clinical  relapses 

Per- 
centage of 
clinical 
relapses 

Average  time  lost  by  each 
man  in  days. 

Treatment 

Once 
only 

Twice 
only 

Three 

or  more 

times 

Total 
nuTQber 

■which 
relapsed 

In 
hospital 

.\ttending 
as  an  out- 
patient 

Total 

Mercury 

alone 
Mercury  and 
Salvarsan 

378 
152 

42 
23-2 

151 
6 

115 
0 

49 
0 

315 
6 

83 
3-9 

66-2 
25-2 

17 -G 
15-8 

83-8 
41 

3.  Prognosis  as  to  Infectivity. — The  sooner  the  contagious  stage  of  the  disease 
can  be  abolished,  the  greater  the  advantage  both  to  the  patient  and  to  the 
communit3^  The  rapidity  of  the  action  of  salvarsan  in  the  early  stages  of 
syphilis  is  remarkable,  and  both  the  primary  sore  and  the  secondary  syphilides 
will  be  found  to  yield  to  this  treatment  in  a  few  days,  where  a  similar  improve- 
ment would  only  be  arrived  at  after  weeks  of  mercurial  treatment. 

4.  Prospects  of  Appearance  of  Tertiary  Symptoms. — The  treatment  of  syphilis 
has  for  its  object,  not  only  the  relief  of  the  early  and  contagious  symptoms,  but 
the  prevention  of  its  progress  into  the  tertiary  period,  and,  if  carried  out  on  the 
principles  previously  indicated,  there  is  a  reasonable  prospect  that  the  disease 
will  be  arrested  before  that  stage  is  arrived  at.  The  best  regulation  for  the 
duration  of  treatment  is  the  Wassermann  test,  and  as  long  as  that  remains 
positive,  the  indication  is  that  treatment  should  be  persisted  in.  If,  after  a 
provocative  injection  of  salvarsan,  the  test  remains  negative,  the  inference  is 
that  the  disease  is  cured. 

But  there  are  certain  conditions  in  which  the  progress  of  the  disease  is  not  so 
favourable,  and  where  considerable  caution  must  be  exercised  before  giving  a 
good  prognosis.  The  combination  of  syphilis  w'ith  tuberculosis  renders  the 
outlook  far  less  hopeful,  since  the  disease  is  then  liable  to  assume  a  malignant 
form  and  one  intractable  to  all  measures  of  treatment.  Chronic  alcoholism  is 
also  a  condition  in  which  the  disease  is  less  amenable  to  treatment,  and  in  which 
obstinate  ulcerative  lesions,  and  visceral  and  arterial  degenerations,  are  liable  to 
supervene.  When  complicated  with  malaria,  Bright's  disease,  or  diabetes,  a  very 
guarded  prognosis  must  be  given. 

The  prospects  of  the  supervention  of  nerve  syphilis  depend  upon  the  duration 
and  efficienc}^  of  treatment,  upon  whether  the  disease  is  accompanied  by  any  of 
the  complications  previously  alluded  to,  and  upon  the  methods  and  habits  of 
the  patient.  The  man  who  is  leading  a  strenuous  and  anxious  business  life  and 
is  overtaxing  his  mental  energies,  is  certainly  more  liable  to  develop  symptoms 
of  nerve  syphilis  than  he  who  is  living  in  the  country  and  enjoying  fresh  air 
and  exercise,  free  from  all  the  cares  and  w-orries  of  business. 

5.  Inlierited  Sypliilis. — The  number  of  cases  of  hereditary  syphilis  is  decreasing, 
as  is  also  their  gravit}'-,  an  improvement  which  may  be  attributed  to  the  more 
efficient  treatment  of  syphilis  in  general  and  to  a  better  recognition  of  the 
danger  of  hereditary  transmission.  Formerly  it  was  impossible  to  state  with 
any  degree  of  accuracy  if  or  when  a  patient  was   cured  of   his   syphilis,   and 


5o6  INDEX     OF     PROGNOSIS 

consequently  many  persons  were  permitted  to  marry  prematurely  ;  but  at  the 
present  time  no  one  who  has  been  infected  with  syphilis  in  the  past  should  be 
permitted  to  marry  until  his  Wassermann  reaction  has  been  proved  to  be  negative. 
In  the  case  of  a  woman  contracting  the  disease  during  pregnancy,  it  is  possible 
by  energetic  treatment  to  modify  the  symptoms  in  the  child,  if  not  to  prevent 
their  appearance.  The  condition  is  one  in  which  the  treatment  by  salvarsan 
is  of  the  utmost  value,  and  the  injections  should  be  given  in  small  doses,  supple- 
mented by  mercurial  treatment,  either  in  the  form  of  injections  or  inunctions. 
The  prognosis  as  regards  the  child  improves  with  each  succeeding  pregnancy, 
and  confident  hopes  may  be  held  out  that  the  mother  will  eventually  be  able  to 
produce  children  free  from  all  hereditary  taint.  The  prognosis  in  the  case  of  a 
child  the  subject  of  hereditary  syphilis  will  depend  upon  the  date  at  which  the 
symptoms  of  the  disease  first  manifest  themselves,  and  the  later  that  date  the 
better  the  prognosis.  Minute  doses  of  salvarsan  administered  intramuscularly 
are  indicated  in  hereditary  syphilis,  followed  by  mercurial  inunctions. 

/.  Ernest  Lane. 
SYPHILIS,  CARDIAC— (See  Cardiac  Syphilis.) 

SYPHILITIC  JOINTS.— There  are  three  varieties  of  syphilitic  joint-disease 
not  infrequently  seen  : — 

1.  Acute  Syphilitic  Epiphysitis,  the  so-called  syphilitic  pseudo-paralysis  of 
infants.  This  indicates  a  severe  type  of  the  disease  which  may  be  fatal,  but  if 
other  signs  are  not  very  extensive,  the  joints  recover  well  under  mercurial 
treatment. 

2.  Synovitis  of  older  Children,  the  painless  hydrops  of  the  knee  which  occurs 
in  children  from  six  to  sixteen,  often  with  interstitial  keratitis.  It  usually  clears 
up  completely  under  treatment,  but  the  writer  has  seen  one  case  in  which  double 
fibrous  ankylosis  resulted. 

3.  Gummatous  Arthritis,  the  so-called  'white  swelling'  of  joints  with  tertiary 
acquired  syphilis,  usually  met  with  in  adults,  and  most  frequently  affecting  the 
knee.  Unless  treatment  is  very  early  and  thorough,  these  cases  are  apt  to  get  a 
stiff  knee,  which  may  also  be  painful ;  and  in  one  or  two  instances  which  the 
writer  has  seen,  a  good  result  was  not  obtained  until  the  joint  was  excised. 

A.  Rendle  Short. 

TABES  DORSALIS. — -The  outlook  in  cases  of  tabes  dorsalis  depends,  to  a 
large  extent,  upon  the  stage  at  which  the  disease  is  first  recognized.  By  the 
time  the  patient  has  become  ataxic  in  his  gait,  with  absent  knee-jerks  and  bladder 
trouble,  the  disease  is  already  well  advanced  ;  and  if,  in  addition,  there  are 
trophic  changes  in  the  skin  or  joints,  gastric  or  other  crises,  and  evidences  of 
cystitis,  the  prognosis  is  correspondingly  worse. 

It  is,  therefore,  highly  important  for  the  phj^sician  to  recognize  the  disease  in 
its  early  or  pre-ataxic  stage,  when  the  patient  is  still  able  to  walk  and  stand 
securely,  and  when  the  chief,  and  perhaps  the  only,  symptoms  consist  in 
paroxysmal  lightning-pains,  generally  in  the  limbs :  these  pains  are  often 
mistaken  for  rheumatism,  since  they  are  aggravated  by  cold  or  damp  weather. 
Or  the  earliest  phenomenon  may  be  some  transient  ocular  palsy,  with  diplopia, 
squint,  or  ptosis.  It  is  commonly  stated  in  text-books  that  the  diagnosis  of  tabes 
in  the  early  stages  is  established  by  the  combination  of  lightning-pains,  reflex 
iridoplegia  and  loss  of  knee-jerks.  But  it  is  generally  possible  to  make  a  dia- 
gnosis long  before  the  knee-jerks  are  lost.  In  many  cases,  the  ankle-jerks  dis- 
appear wliilst  the  knee-jerks  are  still  quite  brisk.  The  diagnostic  significance  of 
loss  of  ankle- jerks  is  therefore  of  the  utmost  value.  Most  important  of  all  is  the 
presence  of  lymphocytosis  of  the  cerebrospinal  fluid.      This  is  the  earliest  and 


TABES    DORS  ALT  S  507 


most  constant  physical  sign  in  tabes  (as  in  general  paralysis),  and  should 
be  looked  for  in  every  doubtful  case.  It  precedes  all  the  other  signs  and 
symptoms. 

The  course  of  tabes,  as  a  whole,  apart  from  special  complications  to  which  we 
shall  refer  later,  is  steadily  downwards  ;  the  patient's  power  of  walking  grows 
gradually  worse,  the  ataxia  being  often  apparently  aggravated  by  the  violence 
of  his  own  efforts.  Some  cases  become  severely  ataxic  in  the  course  of  a  couple 
of  years  after  the  onset  of  the  first  symptoms.  In  others,  the  disease  progresses 
much  more  slowly,  and  the  patient  may  remain  in  the  pre-ataxic  stage  for  many 
years,  complaining  only  of  occasional  lightning-pains.  In  others,  again,  the 
disease  becomes  spontaneously  arrested  at  a  somewhat  later  stage,  and  the 
patient,  already  ataxic,  gets  about  for  an  apparently  indefinite  time.  Some  of 
the  symptoms,  such  as  pains,  early  ocular  palsies,  and  various  visceral  crises,  may 
disappear  as  the  disease  advances ;  but  once  the  patient  has  become  ataxic,  his 
inco-ordination  persists,  though  it  may  sometimes  be  alleviated,  e.g.,  by  means 
of  special  courses  of  exercises. 

Tabes  does  not  necessarily  shorten  life,  and  it  has  been  truly  remarked  that 
many  a  tabetic  patient  outlives  his  physician.  A  few  cases,  however,  run  an 
extraordinarily  rapid  course,  and  may  become  bedridden  within  a  couple  of 
years,  or  even  less.  Thus,  I  recall  the  case  of  a  man  who  acquired  sj^philis  at  the 
age  of  twenty-three.  His  first  tabetic  symptom  was  that  of  transient  squint  at 
thirtv-one.  This  cleared  up  completely  in  a  fortnight.  At  thirty-three  he 
developed  deficient  sensation  in  the  lower  limbs  and  along  the  ulnar  borders  of 
both  upper  limbs.  A  month  later,  the  first  signs  of  ataxia  of  the  legs  appeared, 
and  within  six  weeks  he  became  unable  to  stand  or  walk. 

The  presence  or  absence  of  bladder  trouble  has  an  important  bearing  on  the 
prognosis  of  tabes  ;  and  of  all  the  complications,  this  is  one  of  the  commonest, 
and  one  which  has  a  truly  serious  import.  Cj^stitis,  in  tabes,  is  secondary  to  chronic 
dilatation  of  the  bladder  ;  this  dilatation  again  is  the  result  of  deficient  sensation 
in  the  organ,  so  that  the  patient  does  not  realize  when  the  bladder  is  distended, 
and  may  even  pride  himself  upon  the  length  of  time  during  which  he  is  able  to 
hold  his  water.  If  the  bladder  becomes  habitually  over-distended,  its  contractile 
power  diminishes,  and  a  residuum  of  urine  remains  after  micturition.  This 
residual  urine  gradually  increases,  and  ultimately  becomes  so  large  in  amount 
that  the  imperfectly-contracting  and  dilated  organ  develops  overflow  incon- 
tinence. Either  at  this  stage,  or  earlier,  the  use  of  a  catheter  becomes  necessary  ; 
and  the  patient's  life  now  depends  upon  the  scrupulousness  with  which  an 
aseptic  technique  is  carried  out  from  day  to  day.  Sooner  or  later  the  bladder 
becomes  infected,  and  the  patient  is  now  in  a  still  more  critical  stage,  his  danger 
being  that  of  an  ascending  infection  to  the  kidneys,  with  a  terminal  pyelo- 
nephritis. This  gloomy  sequence  of  events,  however,  is  fortunately  preventable 
if,  at  the  very  outset  of  the  disease,  as  soon  as  we  have  made  our  diagnosis,  we 
instruct  the  patient  to  empty  his  bladder  at  short  intervals  of  three  or  four  hours, 
day  and  night,  independent  of  any  spontaneous  desire  to  do  so,  and  without 
waiting  for  any  sensation  of  distention.  If  the  bladder  is  never  permitted  to 
become  distended,  dilatation  is  prevented ;  and  the  necessity  for  catheterization, 
with  the  subsequent  chain  of  complications  above  referred  to,  is  avoided. 

Tabetic  atrophy  of  the  optic  nerve,  with  progressive  failure  of  vision,  has  an 
important  prognostic  significance  as  regards  the  course  of  the  other  tabetic 
symptoms.  In  cases  with  blindness  from  optic  atrophy,  the  ataxic  symptoms 
are  sometimes  absent  for  many  years  ;  so  that  the  patient,  although  blind,  is  able 
to  walk  steadily,  and  to  use  his  upper  limbs  for  fine  movements  of  various  sorts, 
such  as  t}-pewriting,  etc. 


5o8  INDEX     OF     PROGNOSIS 

The  various  crises  (gastric,  intestinal,  etc.)  usually  occur  comparatively  early 
in  the  disease.  During  the  course  of  a  crisis,  with  its  urgent  pain  and  intractable 
vomiting,  the  patient  may  become  intensely  collapsed  ;  but  the  symptoms  often 
cease  suddenly,  and  recovery  then  takes  place  rapidly,  usually  within  a  few  days. 

So-called  laryngeal  crises  are  generally  of  the  nature  of  exacerbations  of  a 
chronic  bilateral  abductor  palsy,  to  which  is  superadded  some  slight  spasm  or 
hypersemia  of  the  larynx,  producing  urgent  dyspnoea.  The  prognosis  of  such 
attacks  is  correspondingly  grave,  and  unless  promptly  relieved  by  tracheotomy 
or  intubation,  the  attack  may  actually  prove  fatal. 

Perforating  ulcer  on  the  plantar  surface  of  the  great  or  little  toe,  or  on  some 
part  of  the  sole  of  the  foot,  is  a  painless  trophic  affection  which  may  occur  early 
in  the  course  of  the  disease.  Formerly  it  was  taught  that  perforating  ulcers 
progress  from  bad  to  worse,  ultimately  producing  an  ulcer  or  sinus  leading  into 
the  subjacent  joint,  or  even  resulting  in  gangrene  and  necessitating  amputation. 
This,  however,  is  not  necessarily  the  case.  Rest  in  bed  for  a  few  weeks,  and 
simple  antiseptic  dressings,  will  produce  healing  of  the  great  majority  of  such 
ulcers.  Even  where  the  bone  or  joint  beneath  the  ulcer  has  been  implicated, 
a  bony  sequestrum  may  come  away,  and  the  superjacent  tissue  may  then  cicatrize. 

Tabetic  arthropathies — so-called  Charcot  joints — occur  most  frequently  in  the 
knee,  hip,  or  foot,  but  may  affect  the  joints  of  the  upper  limbs,  or  indeed  any  joint 
in  the  body.  They  are  often  multiple,  and  sometimes  symmetrical.  The 
outstanding  characteristic  of  this  variety  of  joint  affection  is  its  painlessness. 
Not  only  is  the  initial  effusion  into,  and  around,  the  affected  joint  unaccompanied 
by  pain,  but  even  when  destructive  changes  are  far  advanced,  with  loss  of 
articular  cartilage,  coarse  crepitus  between  the  bare  ends  of  the  bones,  and 
abnormal  mobility  of  the  joint  from  relaxation  of  its  ligaments,  the  patient  still 
suffers  no  pain.  After  the  affection  has  persisted  for  weeks  or  months,  it  will  be 
observed  that  the  joint  changes  are  not  purely  destructive,  but  that  a  certain 
amount  of  bony  hypertrophy  occurs  in  the  neighbourhood  of  the  affected  joint, 
producing  osteophytic  outgrowths  at  the  margins  of  the  articular  ends  of  the 
bones,  and  often  resulting  in  huge  bony  masses  in  which  the  original  outline  of 
the  bones  becomes  completely  buried,  as  if  it  were  nature's  attempt  to  immobilize 
the  diseased  joint. 

Spontaneous  fractures  of  the  bones,  in  tabetic  patients,  chiefly  occur  in  the 
long  bones,  and  often  in  the  neighbourhood  of  a  joint  which  is  already  the  seat 
of  a  tabetic  arthropathy.  These  fractures  occur  spontaneously,  i.e.,  after 
inadequate  or  trivial  causes.  They  are  absolutely  painless,  and  unless  the 
mechanical  conditions  be  such  as  to  render  locomotion  impossible,  the  patient 
may  continue  to  use  the  broken  limb  without  any  consciousness  of  what  has 
occurred.  The  prognosis  as  to  union  of  such  fractures  is  good,  as  a  rule. 
Most  cases  become  firmly  reunited,  but  with  an  excessive  amount  of  callus. 

Although  ataxia  is  present  in  a  large  proportion  of  cases,  it  is  not  necessarily 
an  early  symptom  ;  many  tabetics  suffer  from  the  disease  for  years  without 
developing  it.  There  seems  to  be  little  doubt  that  physical  exertion  tends  to 
precipitate  its  occurrence.  If,  therefore,  we  establish  our  diagnosis  in  the  pre- 
ataxic  stage  of  the  disease,  we  may  sometimes  succeed  in  retarding,  or  possibly  in 
warding  off  completely,  the  onset  of  ataxic  symptoms,  by  impressing  on  the 
patient  the  necessity  for  abstaining  carefully  from  severe  or  prolonged  muscular 
exertion.  Thus,  for  example,  the  amount  of  walking  he  is  permitted  to  do 
should  never  be  enough  to  induce  the  slightest  fatigue. 

Once  ataxia  has  supervened,  it  may  either  become  slowly  and  insidiously 
worse,  or  it  may  remain  for  years  practically  of  the  same  degree  of  intensity. 
Or  again,  in  other  cases,  it  may  attain  to  an  extreme  degree  with  extraordinary 


TENOSYNOVITIS  509 


rapidity,  within  a  few  weeks,  or  even  days.  An  acutely-advancing  ataxia  of 
this  sort  is  aggravated  by  the  very  energy  with  which  the  patient  strives  to 
overcome  it.  In  some  cases,  the  ataxia  may  even  improve  ;  and  the  patient, 
previously  unable  to  stand  or  walk,  may,  by  practising  carefully-planned  exercises 
under  supervision,  re-educate  his  limbs  and  become  able  to  walk  once  more  with 
only  a  moderate  degree  of  ataxia.  The  cases  which  are  most  likely  to  benefit 
from  such  a  course  of  re-educative  exercises  are  those  in  which  the  disease  has 
advanced  slowly  and  gradually.  In  patients  with  ataxia  of  rapid  onset,  it  is 
wise  to  wait  until  the  ataxic  phenomena  have  apparently  ceased  to  advance, 
before  commencing  re-educative  exercises.  Purves  Stewart. 

TACHYCARDIA. — {See  Pulse,  Irregularities  of  the.) 

TALIPES. — The  prognosis  in  congenital  and  paralytic  talipes  must  be 
considered  separately. 

Congenital  Talipes  Equinovarus. — There  is  no  tendency  to  spontaneous 
improvement  ;  rather  indeed,  unless  carefully  watched,  to  relapse  after 
operation.  Untreated  cases  are  generally  able  to  walk,  but  in  a  very  painful 
and  cumbrous  manner,  lifting  one  foot  over  the  other  at  each  step. 

Given  proper  treatment  before  the  child  has  learnt  to  walk,  it  will  be  possible, 
in  the  milder  degrees  of  the  deformity,  to  obtain  a  perfect  result  ;  but  not  if 
there  is  great  rigidity  or  bony  alteration.  If  treatment  begins  after  walking,  it 
is  often  possible  in  the  milder  cases,  or  in  patients  with  rigidit}''  in  a  bad  position 
not  due  to  bony  change,  by  means  of  tenotomy  and  plaster,  to  get  a  foot 
which  if  unshapely,  will  be  sound  functionally.  If  there  are  bony  changes, 
it  will  be  necessary  to  excise  the  astragalus  or  a  wedge  from  the  os  calcis  and 
cuboid,  and  some  pain  on  walking  far,  and  permanent  deformity  of  the  foot, 
must  then  be  anticipated  in  most  cases,  although  the  operation  will  probably 
effect  great  improvement. 

Much  depends  upon  the  patience  and  perseverance  with  which  the  parents 
bring  the  child  for  supervision.  Up  to  the  age  of  twenty  there  is  a  tendency 
to  relapse,  but  the  relapses  can  be  cured.  Care,  therefore,  is  needed  for  months 
and   years   after   any   operation. 

The  methods  of  treatment  are  fortunately  almost  free  from  risk.  Non- 
union of  tendons  after  tenotomy  is  very  rare,  but  sometimes  a  long,  thin,  weak 
bond  of  union  may  result.  There  are  a  few  cases  on  record  of  aneurysm 
following  nicking  of  the  posterior  tibial  artery. 

Paralytic  Talipes. — It  is  almost  always  possible,  both  in  children  and  adults, 
to  obtain  a  shapely  foot  with  plantigrade  walking  by  means  of  tenotomies, 
tendon-transplantation,  plaster,  and  orthopaedic  apparatus,  but  it  is  not  possible 
to  restore  power  to  the  paralyzed  muscles  after  the  lapse  of  a  year  from  the  onset 
of  the  infantile  palsy.  To  this  statement  one  qualification  must  be  made  :  a 
muscle  which  has  been  long  overstretched  may  recover  a  good  deal  of  its  power 
if  it  is  kept  for  several  weeks  in  a  relaxed  position. 

Reference. — Tubby,  Deformities,  including  Diseases  of  Bones  and  Joints,  vol.  i. 

A.  Rendle  Short. 

TENOSYNOVITIS.— 

Simple. — This  may  be  classified  under  four  headings,  crepitating,  serous, 
purulent,  and  adhesive. 

The  two  former  are  usually  met  with  in  the  tendon-sheaths  around  the  back 
of  the  wrist,  and  are  harmless  and  transient  affections,  though  there  is  a  certain 
tendency  to  relapse.  The  duration  depends  upon  the  time  at  which  efficient 
treatment  is  undertaken  ;  if  a  splint  is  worn  and  iodine  apphed,  it  is  very 
uncommon  for  the  trouble  to  last  more  than  a  week. 


5IO  INDEX     OF     PROGNOSIS 

Purulent  tenosynovitis  is  most  often  met  with  in  the  sheaths  of  the  flexor 
tendons  of  the  fingers.  It  is  very  seldom  dangerous  to  hfe,  except  in  feeble  or 
aged  persons  when  it  has  rapidly  extended  to  the  larger  sheaths  around  the  wrist, 
and  then  gone  on  to  destroy  the  bones  or  joints.  Apart  from  this,  however, 
suppuration  in  a  tendon-sheath  is  a  serious  disease,  because  it  is  almost  certain, 
unless  the  pus  is  let  out  very  thoroughly  and  very  early,  that  a  stiff  finger  will 
result  from  adhesive  tenosynovitis,  and  this  is  such  an  obstruction  that,  for 
many  occupations,  it  is  better  to  amputate  the  finger. 

Tuberculous. — There  are  two  principal  varieties,  the  pulpy  form,  going  on  later 
to  caseation  and  softening,  and  the  melon-seed-body  form,  which  runs  a  much 
more  chronic  course.  There  is  no  essential  difference  between  them  ;  the 
writer  has  found  the  pulpy  form  in  the  extensor  tendon  and  melon-seed  bodies 
in  the  flexor  tendon  of  the  same  finger,  and  also  a  mass  of  pulpy  tissue  at 
the  wrist  containing  a  few  melon-seed  bodies  in  the  middle  of  the  pulp. 

The  prognosis  is  not  very  satisfactory.  In  early  cases,  before  softening  and 
septic  infection  have  occurred,  healing  is  often  to  be  obtained  by  fixation  and, 
if  this  fails,  by  evacuation  and  scraping  of  the  tendon-sheath,  with  the  application 
of  iodine,  iodoform,  or  carbolic  acid.  But,  unfortunately,  the  tendons  may  be 
stiff  and  adherent,  or  the  tuberculous  process  may  recommence  at  a  distance,  in 
the  same  or  another  sheath.  When  suppuration  has  already  occurred  on  an 
extensive  scale,  especially  if  the  joints  are  invaded,  the  prospects  of  useful 
recovery  are  usually  so  small  that  amputation  is  to  be  advised. 

A.  Rendle  Short. 

TESTIS,  NEW  GROWTHS  OF.— The  nomenclature  of  the  new  growths  of 
the  testis  is  very  confused.  The  older  authorities  divided  them  into  fibrocystic 
disease,  sarcoma,  and  carcinoma,  the  first  of  which  often  contained  cartilage 
and  was  supposed  to  be  innocent.  Modern  writers  (Nicholson,  Morriston  Davies, 
Russell  Howard)  deny  that  there  are  any  innocent  tumours  of  the  testis,  except 
the  very  rare  dermoid  cysts.  The  patient  from  whom  Sir  James  Paget's  original 
type-specimen  of  chondroma  was  taken  eventually  died  of  recurrence  in  the 
heart  and  lungs. 

The  modern  classification,  given  by  Morriston  Davies  after  Nicholson,  is  : — 

T,    ■.  I  Solid. 

Embryoma     |  Cystic  (dermoids). 

^       .  J  Encephaloid   (alveolar   or  non-alveolar). 

Carcinoma      \  Scirrhus. 

Sarcoma  (round-celledU 

Endothelioma.     (Rare.) 

Authorities  differ  as  to  the  relative  frequency  of  these  forms.  Carcinoma  and 
sarcoma  are  not  distinguishable  clinically  or  with  the  naked  eye,  and,  as  far  as 
we  know,  the  prognosis  is  the  same.  Some  of  the  embryomata,  including  the 
fibrocystic  and  cartilaginous  growths,  are  much  slower  and  less  malignant  than 
the  soft  vascular  tumours. 

It  should  be  mentioned  that  growths  of  the  testis  are  very  frequently  confused 
with  haematoceles,  and  that  the  patient  may  give  no  history  of  injury  in  the 
latter  case.     This  must  be  borne  in  mind  in  giving  a  prognosis. 

The  Operation  Mortality,  in  treatment  by  castration,  is  very  small  except  in 
broken-down  individuals.  At  St.  Bartholomew's  Hospital,  2  out  of  33  died  as 
a  result  of  this  operation.  From  the  literature,  Kober  reports  5  deaths  in  106 
cases  after  castration  for  sarcoma.  The  more  modern  procedure  of  opening 
up  the  retroperitoneal  tissues  about  the  bifurcation  of  the  aorta  and  inferior 
vena  cava  in  order  to  remove  enlarged  glands,  is  no  doubt  a  serious  opera- 
tion, but  sufficient  cases  have  not  been  reported  to  enable  us  to  judge  of  the 


TETANUS  511 


mortality.     There  were  no  deaths  in  a  dozen  or  fifteen  cases  reported  or  known 
to  the  writer. 

The  End-results  of  operation  for  mahgnant  growths  of  the  testis  are  very 
disheartening.  The  following  statistics  are  available.  They  are  all  collections 
of  cases  from  the  literature,  not  purely  hospital  records,  and  are  therefore  likely 
to  be  unduly  favourable. 


lueporter 

Cases  followed 

Eesult 

Butlin     - 

Kober  (sarcoma)     - 

Chevassu 

53 

48 

100 

6  well  three  years  after. 
j   9  well  three  years  after. 
1    (5  well  less  than  three  years  after. 
19  well  four  years  after. 

In  Kober's  statistics  (1900),  30  out  of,48  followed  were  known  to  have  recurred, 
and  3  more  died  within  a  year.  In  Chevassu's  series,  81  out  of  100  died  within 
a  few  years.  No  doubt  many  of  the  successes  in  the  above  tables  occurred  after 
removal  of  growths  of  the  fibrocystic  or  cartilaginous  type.  The  cures,  therefore, 
are  probably  less  than  20  per  cent.  Many  observers  have  been  impressed  with 
the  great  rapidity  of  recurrence.  "Within  a  few  months  of  the  castration,  there 
is  a  huge  growth  in  the  retroperitoneal  glands.  Nearly  all  the  recurrences  are 
in  the  glands,  and  take  place  within  a  year. 

In  children,  growths  of  the  testis  are  ultra-malignant,  and  cure  is  practically 
never  obtained.  Tumours  of  the  epididymis  are  very  unfavourable.  Operation 
is  useless  if  the  retroperitoneal  glands  can  be  felt  enlarged.  Hard  slow-growing 
tumours  are  much  more  hopeful  than  soft  ones. 

Removal  of  Retroperitoneal  Glands. — Of  late  years,  in  view  of  the  very  un- 
successful results  just  quoted,  several  surgeons  have  made  a  practice  of  removing 
the  retroperitoneal  glands  around  the  bifurcation  of  the  inferior  vena  cava  and 
aorta.  Davies  reports  12  such  cases  from  the  literature,  and  i  of  his  own.  The 
end-results  are  not  given.  Davies's  own  case  recurred.  A  patient  was  submitted 
to  this  operation  recently  at  the  Bristol  Royal  Infirmary  (there  was  a  remarkable 
contrast  between  the  huge  incision  for  the  retroperitoneal  removal,  and  the 
size  of  the  one  gland  found,  which  was  about  as  large  as  a  filbert)  ;  but  within  a 
few  months  the  patient  returned  with  a  large  inoperable  recurrence.  Further 
evidence  is  needed  before  it  can  be  decided  whether  the  glandular  removal  is 
worth  while. 

References. — Butlin,  Operative  Surgery  of  Malignant  Disease,  2nd  ed.  ;  R.  Howard, 
Clin.  Jour,  iqio,  xxxvii,  6  ;  Morriston  Davies,  Lancet,  1912,  i,  418  ;  Chevassu,  Rev.  de 
Chir.  1910,  xli,  628.  ^    j^^,^^ii^  5;,^,^^ 

TESTIS,  TUBERCULOUS.— (See  Epididymitis,  Tuberculous.) 

TETANUS. — The  prognosis  of  tetanus  is  often  difficult,  but  there  are  some 
well-defined  general  principles  laid  down  for  our  guidance.  Great  care  must 
be  exercised  in  this,  even  more  than  in  other  diseases,  to  accept  only  evidence 
based  on  consecutive  series  of  cases,  and  not  on  more  or  less  favourable  reports 
of  individual  successes  picked  out  of  the  literature. 

The  General  Prognosis  of  Tetanus. — Jacobson  and  Pease,  reporting  on  200 
cases  of  this  malady  treated  in  American  hospitals,  state  that  17  per  cent  of 
the  acute  type,  and  56  per  cent  of  the  chronic  type,  recover.  At  the  Bristol 
Royal  Infirmary,  9  out  of  31  have  been  saved,  a  variety  of  methods  of  treatment 
being  adopted. 


512  INDEX     OF     PROGNOSIS 

Prognosis  in  Individual  Cases. — This  varies  with  a  number  of  factors.  Age 
and  sex  are  not  important. 

The  Incubation  Period. — It  is  quite  clear  that  the  general  rule  is  that  a  long 
incubation  period  is  a  favourable  sign;  but  there  are  exceptions.  Of  13  cases 
at  the  Bristol  Royal  Infirmary  in  which  the  symptoms  commenced  within 
ten  days,  2  recovered  (both  mild)  ;  of  11  with  a  longer  incubation  period,  4 
recovered.     When  no  history  of  a  wound  is  obtained,  the  majority  get  well. 

Survival  Period. — Hippocrates  pointed  out,  and  modern  experience  confirms, 
that  the  fifth  day  is  critical  in  this  respect,  that  if  the  patient  survives  it  the 
outlook  is  greatly  improved.  In  the  Bristol  cases  the  majority  of  those  who 
reached  it  recovered. 

Location  and  Original  Treatment  of  the  Wound. — Several  tables  of  statistics 
would  appear  to  demonstrate  that  wounds  of  the  leg  are  the  most  favourable, 
and  wounds  of  the  head  the  least  so.  Patients  with  facial  palsy  (the  Rose 
cephalic  type)  almost,  if  not  quite,  invariably  die.  Thus,  in  the  Bristol  series, 
of  4  head  cases,  all  died  ;  of  wounds  of  the  arm  or  hand,  9  out  of  1 1  died  ;  of 
wounds  of  the  foot  or  leg,  5  out  of  9  died.  The  explanation  is  that  tetanus 
toxin  travels  by  the  nerve-trunks,  and  has  therefore  further  to  travel  to  the 
central  nervous  system  when  the  wound  affects  the  foot. 

Careful  treatment  of  the  original  wound,  long  before  tetanus  has  manifested 
itself,  by  no  means  always  protects  against  attack  or  death.  Out  of  6  of  our 
patients,  4  died,  in  spite  of  such  careful  antiseptic  treatment  just  after  the 
wound  had  been  inflicted.  There  is  some  evidence  that  the  application  of  pure 
carbolic  or  salicylic  acid  is  effectual.  The  injection  of  a  prophylactic  dose  of 
antitetanic  serum  probably  wards  off  the  disease  to  some  extent,  but  there  are 
about  twenty  instances  known  in  which  symptoms  have  come  on  notwithstand- 
ing. The  attack  in  these  cases  is  usually  mild,  however,  and  the  great  majority 
appear  to  have  recovered. 

It  has  already  been  mentioned  that  when  no  wound  can  be  discovered  the 
disease  is  relatively  benign,  and  recovery  is  the  rule. 

The  Severity  of  Symptoms. — If  spasms  are  powerful  and  oft-repeated,  the 
outlook  is  very  grave  indeed,  and  when  the  temperature  rises  (in  the  absence 
of  a  septic  wound),  death  is  not  far  off.  The  cases  that  recover  are  those  that 
show  only  tonic  contraction,  with  slight  spasms  at  intervals  of  many  hours, 
or  none  at  all. 

Prognosis  in  Relation  to  Treatment. — Various  methods  of  giving  the  anti- 
toxin have  come  into  use  of  late,  and  some  data  are  available  with  regard  to 
their  value. 

Colossal  doses  (several  hundred  c.c.)  are  advocated  by  the  manufacturers, 
but  they  are  very  expensive,  and  though  15  out  of  20  cases  were  cured  (Jacobson 
and  Pease),  it  is  not  clear  that  they  were  severe. 

Intracerebral  injection  is,  or  ought  to  be,  given  up,  because  intracranial  abscess 
has  followed  it  more  than  once.  Von  Graff  reports  88  cases  in  the  literature, 
whereof  80  per  cent  died  ;  Sawamura  gives  another  list  in  which  67  per  cent 
died. 

Intraneural  injection  and  intraspinal  injection  are  well  spoken  of,  and  have 
some  theoretical  basis.  Rogers  saved  4  patients  out  of  7  by  giving  the  anti- 
toxin by  all  four  routes — subcutaneous,  intravenous,  intraneural,  and  intraspinal. 
Hofmann  reports  two  series  :  in  the  first,  treated  by  antitetanic  serum  subcu- 
taneously,  7  out  of  13  died  ;  in  the  second,  to  whom  the  antitoxin  was  given 
by  the  intraspinal  route,  only  2  out  of  16  died,  although  4  were  very  severely 
affected. 

Ashhurst  treated  5  patients  within  twenty-four  hours  of  the  onset  of  symptoms 


TONGUE,     CANCER     OF  513 

by  huge  doses  of  antitoxin  (3000  c.c.)  given  by  all  four  routes  (Rogers's  method), 
and  only  i  died  ;  he  also  saved  4  out  of  1 1  cases  in  which  the  incubation  period 
was  less  than  ten  days,  but  only  one  of  these  appears  to  have  had  severe  spasms. 
Altogether,  he  saved  44  per  cent  of  23  cases,  which  is  certainly  very  good. 

Carbolic  acid  treatment  (Baccelli)  consists  in  the  injection  of  a  3  per  cent 
solution  of  carbolic  acid  subcutaneously,  rising  from  3-gr.  doses  until  30-45  gr. 
are  given  in  the  twenty-four  hours,  carboluria  being  taken  no  notice  of.  On 
paper,  the  results  are  enormously  the  best  on  record — 92  out  of  94  '  severe  ' 
cases  recovered,  and  16  out  of  38  '  very  severe  '  cases.  Apparently  there  were 
no  mild  cases  treated  !  The  figures  are,  however,  obtained  by  a  misleading 
method — the  picking  out  from  the  literature  of  the  isolated  successes  of  a  host 
of  Italian  writers,  usually  reporting  only  one  or  two  instances  of  the  disease  each. 
In  spite  of  this  unsatisfactory  advocacy,  the  injections  are  useful  ;  in  two  cases 
of  my  own  they  saved  the  lives  of  patients  who  appeared  to  be  marked  for  death. 
Good  results  are  reported  amongst  the  wounded  in  the  Great  War. 

Magnesiuin  sulphate  (Meltzer)  treatment  has  become  rather  popular.  Three 
c.c.  of  a  25  per  cent  solution  are  injected  into  the  spinal  theca,  and  this  usually 
succeeds  in  controlling  the  spasms.  Phillips  reports  7  consecutive  cases,  of 
whom  4  survived  ;  in  American  literature  16  out  of  28  recovered.  In  2 
instances,  however,  the  respiratory  centre  was  paralyzed ;  i  of  them  died, 
the  other  being  saved  by  artificial  respiration. 

Krokiewicz's  method  of  treatment  by  injecting  emulsion  of  sheep's  brain 
(10  grams  in  saline)  to  divert  the  tetanus  toxin,  is  said  to  have  saved  13  patients 
out  of  16. 

References. — Jacobson  and  Pease,  Ann.  Surg.  1906,  xliv,  321  ;  Hofmann,  Beitr.  z. 
klin.  Chir.  1907,  Iv,  697  ;  Ashhurst,  Amer.  Jour.  Med.  Set.  1913,  cxlvi,  77  ;  Baccelli, 
Berl.  klin.  Woch.  1911,  xlviii,  1021  ;  Phillips,  Proc.  Roy.  Soc.  Mei.  1910,  ii,  Med.  Section, 
39  ;    Keen,  Surgery,  article  "Tetanus."  ^_  i?e«^/^  Short. 

THORACIC  DUCT,  WOUNDS  OF.— Very  alarmist  reports  have  been  given  in 
the  past  as  to  the  probable  fatal  consequences  of  this  accident.  In  actual  practice, 
however,  it  is  certain  that  no  serious  harm  need  be  anticipated.  Apparently 
the  chyle  finds  its  way  into  the  veins  by  some  alternative  channel.  Zesas  has 
collected  the  records  of  49  cases  from  the  literature,  of  which  5  died ;  but  only  in 
one  of  these,  and  that  doubtfully,  had  the  accident  anything  to  do  with  the  fatal 
issue.     Gauze  plugging  sufficed  to  cure  most  ;    some  required  ligature. 

Reference. — Zesas,  Deiit.  Zeits.  f.  Chir.  1912,  197.  A.  Rendlc  Short. 

TIC   DOULOUREUX.— (See  Neuralgia.) 

TONGUE,  CANCER  OF.— Cancer  of  the  tongue  and  floor  of  the  mouth  is 
one  of  the  most  malignant  forms  of  epithelioma,  and  although  there  has  been 
a  considerable  improvement  of  late  in  the  results  of  treatment,  the  outlook  is 
much  graver  than  in  cases  of  cancer  of  the  lip  or  breast.  The  prognosis  may  be 
considered  under  the  following  headings  : — 

I.  Prognosis  apart  from  Operation. — It  is  doubtful  if  any  authentic  cases  have 
ever  recovered,  and  it  is  very  unusual  for  the  patient  to  live  more  than  two  years. 
Occasionally  the  period  may  be  as  short  a  time  as  six  months.  Patients  are 
sometimes  extraordinarily  unobservant,  and  may  appear  to  notice  nothing  wrong 
until  within  a  few  months  of  the  end.  The  average  duration  of  life,  in  cases  not 
operated  on,  may  be  taken  as  about  fourteen  months  from  the  first  onset  of 
symptoms  (Rowntree,  average  of  90  cases).  In  37  cases  operated  on  but 
recurring,  the  duration  of  life  was  seventeen  months  ;  but  possibly  these  were 
rather  slower  growths  from  the  outset. 

33 


514 


INDEX     OF     PROGNOSIS 


The  cause  of  death  is  nearly  always  from  lung  troubles  such  as  septic  pneumonia 
or  abscess  (114  cases  out  of  146  autopsies — Rowntree).  A  few  (9  out  of  146)  die 
from  haemorrhage.  Secondary  growths  in  the  neck  are  almost  constant ;  in  the 
viscera  they  are  rare.  In  147  autopsies  Rowntree  reports  the  following  metas- 
tases :  liver  in  8  cases  ;  lungs  in  7 ;  pleura,  kidney,  and  larynx,  4  each  ; 
suprarenal,  3. 

The  patient's  last  few  months  of  life  are  generally  very  miserable.  The  foul, 
ulcerous  mass  in  the  mouth,  profuse  salivation,  pain  in  the  tongue  and  ear,  and 
inability  to  talk,  constitute  the  principal  part  of  his  sufferings.  The  glands  of 
the  neck  form  a  huge  adherent  mass  which  occasionally  suppurates  and  f ungates, 
or  may  press  on  the  air-passages ;  but  it  is  well  known  that  death  from  glandular 
involvement  is  far  less  terrible  than  that  from  the  growth  in  the  tongue.  Palliative 
methods  of  treatment,  such  as  cutting  the  lingual  nerve,  give  only  a  brief  and 
partial  respite.  Radium  is  less  effectual  for  cancer  in  this  than  in  other  situa- 
tions, and  seldom  delays  the  growth  much. 

2.  The  Mortality  of  Operation. — It  will  be  obvious  that  this  will  vary  much 
according  to  the  type  of  operation  performed,  the  state  of  the  mouth  as  regards 
sepsis,  and  the  stage  which  the  growth  has  reached. 

A  considerable  body  of  reliable  statistics  is  now  available,  from  which  wc 
may  judge  of  the  mortality  with  accuracy.  Some  of  them  are  hospital  figures, 
probably  the  best  information  obtainable.  Others  are  the  results  of  individual 
operators,  which  do  not  appear  to  be  fabricated  in  any  way,  and  a  few  are  collected 
from  the  literature,  which  is  always  unreliable  as  an  indication  of  mortality, 
because  successes  are  reported  while  failures  are  not. 


Table  I. — Mortality  of  Operations  for  Cancer  of  Tongue. 


■niiitehead'a 
operation 

Whitehead  + 
glands  cleared 

Kocher's 
operation 

Syme's 
operation 

Cases 

Died 

Cases 

Died 

Cases 

Died 

Cases 

Died 

Rowntree,     Middlesex     (glands 

usually  left) 
Whitehead  (tongue  only) 

Do.       (all  operations) 
Massachusetts 
Boyd  and  Unwin 
Ehrlich,  Vienna 
Ehrlich,       German     and     Swiss 

literature     -         -          -         - 
Caird  (all  operations) 
Butlin             .         .         -         -         - 

Do.    from  literature,  1887     - 
Bristol  Royal  Infirmary  - 

109 

116 

139 

20 

12 

percent 

10-9 

2-6 

14-3 

5 

8-3 

33 

49 

306 

47 

197 

17 

percent 

24-2 
25 

16 

14-8 

10 

5-8 

32 
29 

percent 

281 
10-3 

9 

47 

per  cen6 

33 

27 

Probable  average 

— 

5 

— 

15 

— 

18 

— 

30 

?-  Simple  removal  of  the  tongue,  or  rather  of  half  the  tongue  in  the  great  majority 
of  cases,  without  touching  the  glands  of  the  neck,  appears  to  have  a  mortality 
of  about  5  per  cent,  though  Whitehead  reports  a  long  series  in  which  he  only  lost 
2-6  per  cent.  He  also  gives  figures  inclusive  of  all  his  operations  (Syme's  method, 
etc.),  with  a  mortality  of  14-3  per  cent.  Rowntree's  figures  for  the  Middlesex 
Hospital  do  not  distinguish  between  the  many  in  which  the  neck  was  left,  and 
the  few  in  which  all  the  glands  were  cleared.  His  statistics  relate  in  part  to 
the  surgery  of  many  years  ago,  and  for  these  two  reasons  the  figure,  10-9  per  cent, 
is  too  high.     The  Bristol  and  Massachusetts  Hospital  patients  are  but  few. 


TONGUE.     CANCER     OF 


515 


In  the  cases  included  in  this  table,  laryngotomy  and  tracheotomy  were  not 
performed. 

Removal  of  half  the  tongue,  followed  by  clearing  the  glands  of  the  neck. — This, 
which  is  now  regarded  as  the  best  form  of  treatment  in  ordinary  cases,  has  a 
mortality  probably  of  about  15  per  cent  in  cases  where  the  two  operations  are 
performed  at  the  same  time  ;  when  they  are  separated  by  an  interval,  it  is 
perhaps  no  more  than  5  or  10  per  cent,  as  in  Butlin's  and  the  Bristol  figures. 
Some  of  the  deaths  in  Caird's  cases  appear  to  refer  to  Syme's  operation.  The 
German  and  Swiss  figures  lack  details  of  method,  and  in  the  Vienna  statistics 
given  by  Ehrlich,  the  neck  and  tongue  were  usually  cleared  at  the  same  time. 
Butlin  records  22  cases  with  4  deaths  when  both  were  dealt  with  at  once,  and 
48  cases  with  only  2  deaths  when  there  was  an  interval  of  a  few  weeks. 

Kocher's  Operation. — Few  modern  statistics  of  this  method,  in  which  the  tongue 
is  removed  by  the  submaxillary  route,  appear  to  be  available.  The  Middlesex 
Hospital  figures,  in  which  the  operation  was  reserved  for  bad  cases,  show  a 
mortality  of  28-1  per  cent.  At  the  Massachusetts  Hospital,  where  it  was  resorted 
to  much  more  freely  in  comparison  with  other  methods,  only  10  per  cent  died. 

Syme's  Operation. — When  the  jaw  has  to  be  divided  to  remove  the  cancer,  the 
outlook  is  necessarily  grave.  The  few  available  figures  suggest  a  death-rate  of 
I  in  3  or  I  in  4. 

The  Prospects  of  Cure. — We  are  now  in  possession  of  sufficient  evidence,  from 
a  variety  of  sources,  to  be  able  to  judge  of  the  prospect  of  a  lasting  cure,  and  as 
we  have  hospital  figures  as  well  as  those  of  individual  surgeons,  we  may  accept 
them  with  some  confidence.  If  recurrence  is  going  to  take  place  in  this  particular 
form  of  cancer,  it  almost  always  does  so  in  less  than  three  years. 


Table  II. — Prospect  of  'Cure  '  after  Operation  for  Cancer  of  the  Tongue. 


Surgeon  or  Hospital 

Operation  performed 

Cases 
opei'ated  on 

Free  from 
recurrence 

Time 
foUowed 

per  cent 

years 

Butlin           .          .          .          . 

All  operations 

175 

31 

3 

Do.            .         -         .         . 

Tongue  only  removed 

41 

29 

3 

Do.           .         .         .         . 

Tongue  and  glands  removed 

57 

A2 

3 

Massachusetts  Hospital 

Tongue    removed,      glands 
usually  left 

58 

17 -2 

3 

Boyd  and  Unwin 

Tongue  and  glands  removed 

31 

19-3 

1 

Caird            .         .         .         . 

Tongue  and  glands  removed 

25 

16 

3 

Ehrlich,  Vienna  cases 

Tongue  and  glands  removed 

40 

13 

3 

Ehrlich,   from    German  and 

Sometimes    glands     also 

f  306  i 

iV.) 

3 

Swiss  literature 

removed 

(         1 

\^l\  Less 

than  3 

Bristol  Royal  Infirmary 

All  cases 

29 

27-5 

Do. 

Glands  left 

12 

8 

2 

Do. 

Glands  and  tongue  removed 

17 

41 

2 

Taking  all  cases  and  all  operations  together,  it  will  be  seen  that  the  percentage 
of  patients  cured  is  probably  from  15  to  20.  Butlin's  extensive  figures  give  a 
much  better  result  than  this,  but  hospital  statistics  are  less  favourable  than  his. 

It  makes  a  great  difference  to  the  prognosis  whether  or  no  the  neck  is  cleared  of 
glands  as  a  routine,  even  when  no  enlarged  glands  can  be  felt.  Thus  Butlin 
reports  :  glands  left,  29  per  cent  cured  ;  glands  removed,  42  per  cent  cured. 
In  our  Bristol  figures,  the  writer  finds  :  glands  left,  8  per  cent  cured  ;  glands 
removed,  41  per  cent  cured.  Several  operators  fail  to  get  such  good  success  in 
spite  of  clearance  of  the  neck.     The  Vienna  figures  are  very  poor  (13  per  cent 


5i6  INDEX     OF     PROGNOSIS 

cured)  ;  Ehrlich's  report  of  German  and  Swiss  literature  shows  that  of  306  cases, 
19  per  cent  were  well  three  years,  and  a  further  11  per  cent  still  free  from  recur- 
rence for  a  shorter  period. 

We  may  conclude  that  about  a  third  of  cases  operated  on  by  removal  both 
of  tongue  and  neck  glands  will  be  cured.  This  is  a  much  better  result  than 
was  obtained  years  ago. 

Information  as  to  the  prospect  of  cure  in  special  circumstances  is  not  so 
complete.  When  it  is  necessary  to  split  the  jaw  (Syme's  operation),  recurrence 
is  very  probable.  Of  five  Bristol  cases  and  nine  Massachusetts  Hospital  (14  in 
all)  not  one  was  cured.  Statistics  of  Kocher's  operation  do  not  appear  to  be 
available. 

In  almost  all  the  patients  mentioned  in  the  table,  only  half  the  tongue  was 
removed.  Probably  slightly  better  results  could  be  got,  at  the  cost  of  severe 
crippling,  by  a  total  removal. 

When  glands  are  palpable  in  the  neck,  the  outlook  is  very  grave,  but  not 
hopeless  ;  the  Massachusetts  records  show  six  cured  in  spite  of  this  sign.  In  one 
of  our  Bristol  cases  the  glands  proved  to  be  tuberculous.  Operation  for  recur- 
rence occasionally  gives  a  cure.  Butlin  records  two  living  respectively  8  and 
13  years,  out  of  eight  operations  for  recurrence  in  the  neck  glands. 

The  Time  and  Situation  of  Recurrence. — In  modern  practice,  recurrence  in  the 
neck  and  in  the  mouth  occurs  with  equal  frequency.  In  older  days,  such  as  is 
represented  by  the  Middlesex  Hospital  figures,  which  go  back  for  many  years, 
a  more  restricted  removal  was  attempted  and  local  recurrence  was  commoner. 

Table  III. — Site  of  Recurrence. 


Surgeon  or  Hospital 

Cases 

Recurred  in  glands 
only 

Recurred  in  mouth 

Rowntree,  Middlesex  Hospital    - 

Butlin 

Bristol  Royal  Infirmary     - 

90 
90 
14* 

33 
45 

7 

57 

45 

G 

*  One  case  recurred  in  the  spine. 

Rowntree  found  that  glandular  recurrence  averaged  seven  months  after 
operation,  and  local  recurrence  six  months.  In  two  of  our  Bristol  cases  there 
Wets  freedom  from  symptoms  for  nearly  three  years,  one  recurring  in  the  tongue 
and  the  other  in  the  neck. 

The  Condition  after  Operation. — Removal  of  half  the  tongue  usually  makes 
but  little  difference,  eventually,  to  the  speech.  One  of  our  Bristol  cases,  a  school- 
master, could  talk  perfectly.  Swallowing  is  also  unaffected.  Even  after  bilateral 
removal  the  patient  may  be  quite  intelligible,  but  there  is  of  course  marked 
speech  delect  in  these  cases.  One  can  almost  always  promise  that  the  speech  will 
be  interfered  with  much  less  by  the  operation  than  by  the  progress  of  the  growth. 

If  there  is  no  local  recurrence,  the  patient's  condition  is  undoubtedly  far  less 
miserable  than  it  would  have  been  apart  from  the  operation,  because  the  glands 
of  the  neck  do  not  give  rise  to  the  horrible  foetid  mouth  condition.  Even  if  the 
cancer  returns  in  the  mouth,  there  is  often  six  months  or  more  of  comfort  first. 

References. — Rowntree,  Archiv.  Middlesex  Hospital,  1906,  vii,  p.  131  ;  ^Whitehead, 
Practitioner,  1903,  Lx.x,  585  ;  Greenough  and  others  (Massachusetts  Hospital  figures)  ; 
Boston  Med.  and  Surg.  Jour.  1909,  cl.x,  563  ;  Boyd  and  Unwiii,  Practitioner,  1903,  Ix.k, 
626;  Ehrlich,  Arch.  f.  klin.  Chir.  1909,  Bd.  88,  s.  427:  Caird,  Edin.  Med.  Jour. 
N.S.,  vi,  19 1 1,  5  ;  Butlin,  The  Operative  Surgery  of  Malignant  Disease,  London,  1900, 
2nd  ed.  150  ;  Butlin,  Brit.  Med.  Jour.  190Q,  i,  i  ;  A.  Rendle  Short,  Brit.  Med.  Jour 
1912,  i,  877  (an  amplified  account  is  here  made  use  of).  ^.  Rendle  Short. 


TRYPANOSOMIASIS  517 


TONGUE,  PAPILLOMA  OF.— This  condition  very  seldom  gets  well  apart 
from  treatment,  but  an  early  free  removal  usually  leads  to  cure.  It  must  be 
borne  in  mind,  however,  that  in  persons  over  40  the  majority  of  these  cases 
undergo  malignant  changes,  and  what  appears  to  be  a  simple  tumour  often 
returns  in  a  few  months  or  years.  ,4.  Rendle  Shcrf. 

TCNGUE,  SARCOMA  OF. — There  are  about  fifty  cases  of  this  rare  disease 
in  the  literature,  but  probably  only  about  thirty  are  worthy  of  acceptance.  The 
outlook  is  not  so  grave  as  in  sarcoma  generally,  and  is  better  than  that  of  cancer 
of  the  tongue.  Of  26  cases  followed  through  after  removal,  11  were  cured  (7 
over  three  years)  and  13  recurred. 

Referexce. — Fripp  and  Jocelyn  Swan,  Practitioner,  1903,  Ixx,  673. 

A.  Rendle  Short. 
TRIGEMINAL  NEURALGIA. — {See  Neuralgia,  Trigeminal.) 

TROPICAL  FEVERS. — The  so-called  tropical  diseases  vary  in  severity. 
Some,  like  phlebotomus  fever,  are  less  severe  than  uncomplicated  influenza,  but 
even  in  these  cases  there  is  often  prolonged  depression  and  a  susceptibility  to 
intercurrent  disease.  Others  are  variable,  for  in  some  outbreaks  there  will  be 
a  large  proportion  of  singularly  mild  cases.  On  the  whole,  the  prognosis  of 
diseases  in  which  there  is  a  known  specific  treatment  depends  on  early  diagnosis, 
on  correct  treatment  when  that  is  known,  and  on  prevention  of  complications 
or  of  intercurrent  diseases.  The  prognosis  is  unfavourable  in  the  severe  diseases 
where  no   effective  specific  treatment  is  known,   such  as  plague  and  leprosy. 

Kala-azar  (Dum-dum  Fever,  Infantile  Splenomegaly,  or  Leishmaniasis)  is  to 
some  extent  controllable  ;  but  when  the  viscera,  liver,  and  spleen  are  affected, 
the  prognosis  is  most  unfavourable  in  adults,  and  little  less  so  in  children. 

Delhi  Boil  and  other  forms  of  cutaneous  Leishmaniasis  are  not  dangerous  to 
life,  but  recovery  is  slow,  often  taking  one  to  two  years. 

Phlebotomus  Fever  and  Dengue  Fever  have  practically  no  mortality. 

Mediterranean  Fever  has  a  good  prognosis,  and  the  case-mortality  directly 
due  to  the  disease  is  i  per  cent. 

In  all  these  diseases  there  is  often  prolonged  debility,  and  sufferers  are  sus- 
ceptible to  other  affections.  c.  W.  Daniels. 

TRYPANOSOMIASIS. — The  natural  course  of  this  infection  is  to  terminate 
as  sleeping-sickness  ;  probably  amongst  natives  there  are  a  few  natural  recoveries 
before  nerve  symptoms  have  manifested  themselves.  In  Europeans,  when  the 
terminal  stage  is  reached,  whether  convulsions,  coma,  or  sleeping-sickness, 
recovery  does  not  take  place.  In  the  earlier  stages,  the  disease  can  be  controlled 
and  life  prolonged  even  in  the  worst  form,  Rhodesian  trypanosomiasis  ;  the 
longest  duration  of  life  in  this  infection  has  been  three  years  ;  but  though  the 
progress  can  be  checked,  most  cases  have  terminated  fatally  in  less  than  a  year. 
When  the  infection  is  from  Nigeria,  Uganda,  Congo,  or  the  Gold  Coast,  control 
is  easier  and  more  absolute,  and  with  long-continued  treatment  actual  cure 
apparently  takes  place  ;  instances  of  Europeans  living  and  free  from  symptoms 
twelve,  eight,  and  seven  years,  as  well  as  for  shorter  periods,  from  the  date  when 
the  disease  was  first  diagnosed,  are  on  record. 

In  the  milder  form,  death,  when  it  occurs,  is  the  result  of  intercurrent  disease 
such  as  pneumonia.  In  the  Rhodesian  type,  death  results  from  the  nervous 
manifestations  or  from  cardiac  failure. 

The  knowledge  of  the  disease  is  so  recent,  and  the  advances  in  our  knowledge 
of  treatment  have  been  so  rapid,  that  there  is  good  reason  for  the  hope  that  this 
disease,  controllable  even  in  its  worst  form,  may  be  curable  ;    so  far,  however. 


5i8 


INDEX     OF     PROGNOSIS 


death  has  always  occurred    in  the  Rhodesian  cases,  usually  in  a  few  months, 
though  one  survived  for  three  years. 

The  South  American  form,  due  to  a  schizotrypanosome,  has  not  been  observed 
in  England  ;    the  prognosis  is  unfavourable.  C.  W.  Daniels. 

TUBAL  DISEASE.— (5ee  Salpingitis.) 

TUBAL  PREGNANCY.— (See  Ectopic  Pregnancy.) 

TUBERCULOSIS. — [See  C^cum,  Enteritis,  Epididymitis,  Arthritis,  Lymph- 
adenitis, AND  Peritonitis,  Tuberculous  ;  Larynx,  Tuberculosis  of  ;  Pul- 
monary Tuberculosis.) 

TYPHOID  FEVER. — There  are  several  factors  which  influence  the  prognosis 
in  this  disease,  and  the  most  important  of  them  are  :  (i)  The  age  of  the  patient ; 
(2)  The  sex ;  (3)  The  character  of  the  attack  ;  (4)  The  presence  of  certain  symptoms  ; 
(5)    The  occurrence  of  certain  complications  ;    and  (6)  The  treatment. 

I.  Age. — The  following  figures,  derived  from  the  records  of  21,371  patients 
admitted  into  the  hospitals  of  the  Metropolitan  Asylums  Board  during  the  years 
1871  to  1907,  indicate  to  what  extent  age  is  of  importance  in  prognosis  in  respect 
of  recovery  : — 

Fatality  according  to  age. 


Age 

Fatality            | 

Age 

Fatality 

per  cent             i 

per  cent 

Under    5 

9-6           1 

ao  to  39 

25-5 

5  to    9 

7-6 

40  to  44 

27-1 

10  to  14 

10-4 

45  to  49 

28  0 

15  to  19 

15-7 

50  to  60 

) 

20  to  24 

18-8 

and  upwards 

32-4 

25  to  29 

22-5 

30  to  34 

24-3 

From  this  table  it  will  be  seen  that  the  most  favourable  ages  are  those  between 
five  and  ten  years,  and  those  under  five  the  next  most  favourable.  Over  ten 
years,  the  fatality  steadily  increases  from  10-4  to  32-4  per  cent  as  the  age  rises. 
One  of  the  reasons  for  the  lower  fatality  under  ten  is  the  infrequency  of  the 
serious  complications  of  haemorrhage  and  perforation  at  those  ages  ;  from  which 
fact  it  may  be  inferred  that  deep  and  extensive  ulceration  of  the  bowel  is  not  so 
common  in  children  as  in  adults. 

2.  Sex. — The  prognosis  is,  on  the  whole,  slightly  more  unfavourable  in  the 
male  than  in  the  female  sex.  The  total  fatality  of  the  21,371  cases  quoted 
above  was  16-3  per  cent ;  amongst  these,  the  fatality  for  males  was  i6-8  per  cent 
and  for  females  15-9  per  cent. 

3.  Character  of  the  Attack. — All  who  have  had  a  wide  experience  of  typhoid 
fever  recognize  that  the  clinical  characters  of  the  cases  which  come  under  their 
observation  vary  considerably  from  time  to  time.  In  some  years  the  disease  is 
more  fatal  than  in  others.  Thus,  at  the  Eastern  Hospital,  the  annual  fatality 
has  varied  during  the  course  of  twenty-one  years  from  6  to  28  per  cent.  The 
variation  has  been  quite  irregular.  The  incidence  of  complications  also  varies 
in  much  the  same  way.  Doubtless  there  are  several  factors  which  have  an 
influence  on  the  character  of  the  attack.  Age  has  already  been  mentioned. 
Besides  this,  there  are  the  factors  of  the  virulence  of  the  particular  typhoid 
bacilli  concerned,  and  the  resisting  power  of  the  patients.  Possibly,  too,  the 
dosage  (i.e.,  the  number  of  the  bacilli  with  which  the  patient  has  been  infected) 


TYPHOID    FEVER  5i9 


is  of  importance.     There  are  reasons  for  believing  that  the  larger  the  dose,  the 
shorter  the  incubation  period  and  the  more  severe  the  attack. 

4.  The  Presence  of  Special  Symptoms. — The  following  symptoms  must  always 
be  regarded  with  apprehension  :  A  continuously  frequent  pulse,  130  to  140  or 
over,  more  especially  if  it  is  at  the  same  time  dicrotic  (a  dicrotic  pulse,  provided 
that  the  pulse-rate  is  not  too  frequent,  is  not  necessarily  a  bad  sign)  ;  cutaneous 
haemorrhages  ;  cyanosis,  which  may  be  due  either  to  a  faihng  heart  or  to  hypo- 
static congestion  ;  coma  or  semi-coma,  with  muttering  delirium  and  subsultus 
tendinum  ;  frequent  action  of  the  bowels,  with  loose  and  offensive  stools  ; 
tympanites  ;  a  dry,  fissured  tongue  ;  involuntary  passage  of  the  urine  and  faeces  ; 
a  strong  presentiment  of  death. 

A  continuously  high  temperature  (103°  to  104°  F.)  is  not  of  necessity  unfavour- 
able, unless  accompanied  by  some  of  the  symptoms  just  mentioned.  But  if  the 
temperature  shows  no  signs  of  falling  after  four  weeks  of  illness,  the  outlook 
becomes  less  bright.  A  rigor,  though  an  alarming  symptom,  is,  on  the  whole, 
not  an  unfavourable  one,  unless  it  is  accompanied  by  symptoms  indicative  of 
perforation,  of  which  it  may  be  one  of  the  signs.  Rigors  occur  under  a  great 
variety  of  conditions  in  typhoid  fever.  Often  they  are  quite  inexplicable.  A 
rigor  during  convalescence  may  be  the  herald  of  a  relapse. 

It  has  been  shown  by  Harold  Scott  that  the  prognosis  is  aided  by  a  careful 
study  of  the  serum  (Widal)  reactions.  It  is  well  known  that  the  property  of 
agglutinating  the  specific  bacilh  is  not  usually  present,  at  any  rate  in  any  marked 
degree,  during  the  first  few  days  of  the  illness.  According  to  Scott,  in  a  case  of 
average  severity  the  reaction  is  usually  quite  distinct  by  the  seventh  day  of  the 
fever.  If  it  occurs  as  early  as  the  third  or  fourth  day,  the  case  is  most  likely  to 
run  a  mild  course.  On  the  other  hand,  if  the  appearance  of  the  reaction  is  delayed 
to  beyond  the  end  of  the  first  week,  the  case  is  likely  to  be  very  severe.  In  some 
of  the  most  serious  cases,  the  reaction  continues  to  be  negative  for  some  three  or 
four  weeks  after  the  beginning  of  the  illness. 

5.  Complications. — The  occurrence  of  almost  any  complication  affects  the 
prognosis  unfavourably,  even  though  it  may  be  to  a  shght  degree  only,  because 
it  prolongs  the  course  of  the  illness  and  keeps  up  the  risk  of  additional  complica- 
tions. But  some  are  much  more  grave  than  others.  The  two  worst  are 
perforation  and  haemorrhage. 

Perforation  is  by  far  the  most  serious  complication  of  typhoid  fever,  and 
accounts  for  a  fourth  to  a  third  of  the  total  number  of  fatal  cases.  It  occurred 
in  3-41  per  cent  of  8997  cases  which  were  under  treatment  in  the  hospitals  of  the 
Metropolitan  Asylums  Board  during  the  ten  years  1900  to  1909  ;  but  the  incidence 
varied  in  different  years  from  2-7  to  5-1  per  cent.  Unless  remedied  by  operation, 
perforation  is  nearly  always  fatal,  for  not  more  than  i  per  cent  of  the  cases 
recover.  Usually,  death  from  peritonitis  results  in  three  to  four  days  from  the 
perforation,  but  occasionally  the  fatal  event  is  due  to  collapse,  and  may  occur 
within  a  few  hours  or  even  minutes.  Further  consideration  of  this  complication 
will  be  given  later  when  the  treatment  is  discussed. 

Occasionally  one  is  able  to  diagnose  peritonitis  without  being  certain  that  it  is 
due  to  perforation.  But  the  former  is  as  grave  a  complication  as  the  latter, 
because  it  is  nearly  always  due  to  it,  though  the  symptoms  may  not  be  clear. 

The  symptoms  of  perforation  are :  sudden,  and  often  (but  by  no  means  always) 
severe,  pain  in  the  abdomen,  especially  in  the  right  iliac  region  ;  pain  on  palpation 
of  the  abdomen  ;  alteration  in  the  condition  of  the  abdomen,  usually  in  the 
direction  of  some  distention  ;  rigidity  of  the  abdominal  wall,  especially  on  the 
right  side  ;  thoracic  respiration  ;  an  increase  in  the  pulse-rate  ;  a  sudden  rise  or 
fall  of  temperature  ;   occasionally  vomiting  and  a  rigor  ;    collapse. 


520  INDEX     OF     PROGNOSIS 

Hcemorrhage  from  the  bowel  is,  next  to  perforation,  the  most  serious  compli- 
cation. It  is  considerably  more  frequent  than  the  graver  event,  and  was  observed 
in  9  per  cent  of  the  cases  referred  to  above.  In  these  statistics,  only  those  cases 
of  haemorrhage  are  included  which  were  sufficiently  severe  to  call  for  treatment. 
Both  haemorrhage  and  perforation  are  met  with  in  the  most  serious  cases  of 
typhoid  fever  ;  and  neither  of  them  can  occur  except  when  the  bowel  has  been 
deeply  ulcerated.  Haemorrhage  is  seldom  fatal  of  itself,  at  any  rate  immediately  ; 
but  a  repeated  loss  of  moderate  amounts  of  blood  weakens  the  patient,  and  so 
conduces  to  and  hastens  a  fatal  termination.  As  bleeding  in  any  considerable 
amount  cannot  take  place  unless  the  bowel  is  deeply  ulcerated,  it  is  not  surprising 
to  find  that  perforation  is  preceded  by  haemorrhage  in  not  a  few  cases  :  I  have 
observed  it  in  about  one-fifth  of  the  cases  of  perforation  at  the  Eastern  Hospital. 
Profuse  arterial  is  more  serious  than  profuse  venous  haemorrhage.  Occasionally 
haemorrhage  is  concealed,  that  is  to  say,  the  blood  does  not  pass  per  anum.  In 
that  case  it  may  be  diagnosed  by  the  occurrence  of  pallor,  restlessness,  a  frequent, 
feeble  pulse,  collapse,  and  sighing  respiration.  The  combination  of  these 
symptoms  is  most  serious. 

None  of  the  remaining  complications  of  typhoid  fever,  whether  serious  or  not, 
are  at  all  frequent  ;  they  do  not  exceed  3  per  cent.  The  most  grave  are  lobar 
pyieuinonia,  meningitis,  and  nephritis.  These  are  dangerous  to  life.  Ulceration 
of  the  larynx  is  usually  met  with  in  severe  cases  only.  If  the  patient  recovers, 
permanent  stenosis  of  the  larynx  may  remain.  Hemorrhagic  typhoid  fever,  in 
which  cutaneous  and  subcutaneous  haemorrhages  and  bleeding  from  various 
mucous  membranes  occur,  is  almost  invariably  fatal. 

A  relapse  is  to  be  expected  in  about  10  per  cent  of  the  cases.  Usually  it 
begins  mthin  three  weeks  of  the  final  cessation  of  the  fever.  In  a  few  cases, 
however,  I  have  known  a  relapse  to  occur  after  a  longer  interval,  even  six 
weeks.  It  is  impossible  to  prognosticate  the  occurrence  of  a  relapse  with 
any  degree  of  certainty.  But  J.  D.  RoUeston  states  that  the  diazo-reaction 
reappears  at  its  commencement,  and  that  the  disappearance  of  the  abdominal 
reflex  is  also  a  warning.  This  reflex  vanishes  during  the  acute  stage  of  most 
cases  of  typhoid  fever,  but  reappears  when  the  temperature  has  become  normal. 
The  fatality  of  relapses  is  about  half  that  of  primary  attacks  ;  and  they  are  less 
likely  than  the  latter  to  be  accompanied  by  complications. 

There  are  a  few  complications  which  are  prone  to  show  themselves  more 
often  during  convalescence  than  during  the  febrile  stage  of  the  disease.  Of 
these  the  most  common  are  venous  thrombosis  and  acute  periostitis  and  necrosis. 
They  occurred  respectively  in  2-3  and  1-2  per  cent  of  the  cases  referred  to.  The 
former  may  follow  an  acute  phlebitis,  which  may  arise  in  almost  any  vein,  but  is 
met  with  most  often  in  one  of  the  veins  of  the  leg.  But  most  frequently  thromb- 
osis is  due  to  a  combination  of  a  sluggish  circulation  and  an  altered  condition 
of  the  blood.  The  veins  most  frequently  affected  are  those  of  the  left  thigh  and 
leg,  which  become  swollen.  It  is  usually  months,  and  it  may  be  years,  before 
the  limb  regains  its  normal  state.  Sometimes  the  oedema  is  permanent.  In  this 
complication  there  is  always  some  risk  of  the  detachment  of  a  fragment  of  clot, 
and  therefore  of  pulmonary  embolism  or  cardiac  thrombosis  ;  but  fortunately 
these  results  are  rare. 

Acute  periostitis,  which  may  result  in  necrosis  of  the  underlying  bone,  may 
arise  at  any  time  after  the  acute  stage  of  typhoid  fever.  Usually  it  comes  on 
within  the  first  few  weeks,  but  it  has  been  known  to  show  itself  years  after  an 
attack.  Sometimes  a  definite  sequestrum  forms  ;  in  others,  the  necrosed  bone 
crumbles,  and  these  cases  are  prone  to  become  tedious  and  to  resist  treatment. 
The  bones  most  frequently  affected  are  some  of  the  long  bones,  especially  of 


TYPHOID     FEVER  521 


the  leg  ;  but  almost  any  bone  in  the  body  may  be  the  seat  of  the  inflammation. 
Rarely  are  the  bones  forming  a  joint  involved,  but  when  they  are,  the  joint  may 
be  permanently  damaged. 

In  '  typhoid  spine  '  there  is  a  periostitis  of  the  vertebrae.  This  complication 
is  rare.  It  has  been  met  with  in  the  male  more  frequently  than  in  the  female  sex. 
The  course  of  the  disease  is  prolonged,  extending  to  several  months  or  a  year  ; 
but  recovery  is  usually  complete. 

In  a  few  cases  an  attack  of  typhoid  fever  is  followed  by,  or  it  would  be  more 
correct  to  say  becomes  merged  in,  one  of  acute  dementia  (mania  or  melancholia). 
As  a  rule  this  condition  is  connected  with  a  very  severe  attack  of  the  fever,  but 
I  have  known  it  follow  quite  a  slight  attack.  The  prognosis  is,  on  the  whole, 
favourable,  and  the  patient  recovers  in  about  a  year's  time. 

Influence  of  Pregnancy. — I  have  had  under  my  care  38  women  who  have  been 
attacked  by  typhoid  fever  during  pregnancy.  Of  these,  8  died,  a  fatality  of 
21  per  cent,  which  is  about  the  average  rate  amongst  women  of  the  child-bearing 
ages.  Miscarriages  or  premature  confinements  took  place  in  27  instances  ;  all 
the  fatal  cases  occurred  amongst  these  27.  If  a  pregnant  woman  is  attacked  by 
typhoid  fever  before  the  child  is  viable,  miscarriage  is  very  likely  to  occur  ;  in 
fact  it  did  occur  in  25  of  30  such  cases.  If  she  is  attacked  after  the  child  is 
viable,  there  is  a  better  chance  of  her  going  to  full  term  ;  though  even  then  the 
child  may  be  weak  and  frail.  Some  of  the  women  left  the  hospital  undelivered. 
Supposing  that  each  of  of  them  was  subsequently  confined  of  a  healthy  child, 
then,  of  38  pregnancies,  8  ended  favourably  both  to  mother  and  infant.  But 
certainly  in  28  of  the  38  cases  the  child  was  either  born  dead,  or  died  within  a  few 
hours  of  birth.     The  prognosis,  therefore,  in  the  case  of  the  child,  is  bad. 

6.  Treatment. — Of  few,  if  any,  of  the  acute  infectious  diseases  of  this  country 
has  more  been  written  concerning  treatment  than  has  been  written  of  typhoid 
fever.  Baths  (cold  and  warm),  intestinal  antiseptics,  liberal  feeding,  semi- 
starvation,  copious  water-drinking,  serum  and  vaccines,  have  all  had,  and  still 
have,  enthusiastic  supporters,  each  of  whom  proclaims  that  his  is  the  best  treat- 
ment, and  indeed  the  only  one  worthy  of  consideration.  But  unless  the  observer 
has  at  his  disposal  a  very  large  number  of  cases,  extending  over  a  considerable 
series  of  years,  the  conclusions  he  draws  from  them  are  likely  to  be  highly 
erroneous,  on  account  of  the  natural  variation  in  the  severity  of  the  disease  from 
one  year  to  another. 

The  most  extensive  series  of  cases  in  which  a  particular  form  of  treatment 
was  contrasted  with  another,  is  that  given  by  F.  E.  Hare.  Of  1828  consecu- 
tive cases  treated  during  the  years  1882  to  1886  in  the  Brisbane  General  Hospital, 
Queensland,  by  the  '  expectant  '  method,  271  died,  a  fatality  of  14-8  per  cent. 
This  is  about  the  average  fatality  in  most  places  under  this  form  of  treatment. 
Of  1902  consecutive  cases  treated  in  the  same  hospital  during  the  years  1887  to 
1896  with  cold  or  tepid  baths,  143  died,  a  fatality  of  7-5  per  cent.  The  variation 
in  fatality  in  the  first  group  was  from  13-3  to  17-0  per  cent,  whereas  in  the  second 
it  was  from  1-3  to  11-3  ;  that  is  to  say,  the  highest  annual  fatality  amongst  the 
patients  treated  with  baths  was  lower  than  the  lowest  of  those  who  underwent 
the  '  expectant  '  method.  These  figures  are  strikingly  in  favour  of  the  bath 
treatment.  I  cannot  bring  forward  so  large  a  series  of  cases  ;  but,  from  my 
clinical  experience,  I  am  persuaded  that  the  bath  treatment  is  better  than  any 
other  of  those  which  have  been  given  a  fairly  extended  trial  ;  and  that,  other 
things  being  equal,  the  prognosis  is  more  favourable  in  cases  which  are  bathed 
than  in  those  which  are  not.  But  the  bathing  must  be  commenced  fairly  early 
in  the  disease. 

It  is  too  early  to  give  a  decided  opinion  as  to  the  value  of  the  most  recently 


522  INDEX     OF     PROGNOSIS 

introduced  specific  metliods  of  treatment  by  antityphoid  serum  and  vaccines, 
especially  of  Besredka's  sensitized  vaccines ;  but  the  vaccine  treatment  appears 
promising.  Of  475  cases  treated  in  this  manner,  collected  and  reported  up  to 
September,  1912,  by  J.  G.  Callison,  31  died,  a  fatality  of  6-5  per  cent.  There  was 
also  a  low  relapse-rate  in  these  cases,  viz.,  also  6-5  per  cent.  Callison's  figures 
have  recently  (Sept.,  191 3)  been  extended  to  11 20  by  Walters,  with  much  the 
same  conclusions.  In  this  series  there  were  71  deaths,  a  fatality  of  6-3  per  cent. 
The  results  obtained  by  Chantemesse,  of  Paris,  with  his  serum,  are  extremely 
good  ;    but,  unfortunately,  his  remedy  is  not  on  the  market. 

As  regards  the  diet  of  typhoid  patients,  there  is  some  evidence  to  show  that 
the  more  liberal  scale  introduced  again  of  recent  years  conduces  to  a  lower  fatality 
and  complication-rate,  and  to  a  more  speedy  convalescence,  than  does  the 
exclusive,  or  almost  exclusive,  milk  diet.  To  obtain  the  best  results,  the  diet- 
scale  should  be  carefully  planned,  so  that  the  patient  receives  the  equivalent  of 
3000  to  4000  calories  a  day  in  various  food-stuffs,  given  in  proper  proportions. 

Surgical  Treatment. — I  am  not  aware  that,  in  respect  of  the  complications, 
there  is  any  one  treatment  that  is  of  more  certain  value  than  another,  with  the 
exception  of  perforation  and  peritonitis.  It  has  been  stated  above  that  this 
complication  is  extremely  fatal,  and  that  not  more  than  i  per  cent  of  those  who 
fall  a  victim  to  it  recover.  That  observation  applies  to  cases  which  are  not 
treated  surgically.  There  can  be  no  question,  now,  that  the  patient's  chances  of 
recovery  are  considerably  enhanced  if  the  peritoneal  cavity  is  opened  and  the  ulcer 
which  has  perforated  is  sutured.  While  the  reports  of  published  cases  show  that 
hardly  any  case  is  hopeless,  yet  there  is  one  condition  which  especially  makes  for 
success,  and  that  is  that  the  operation  shall  be  performed  as  soon  as  possible 
after  the  perforation  has  occurred.  A  few  hours'  delay  will  make  all  the  difference. 
Therefore  the  physician  must  be  constantly  on  the  watch  for  the  symptoms  of 
perforation,  and  must  be  prepared  to  call  the  surgeon  to  his  aid,  not  only  as  soon 
as  he  is  fairly  certain  that  there  is  perforation,  but  even  when  he  can  go  no 
further  than  to  state  that  most  probably  it  has  taken  place.  By  operating  early, 
the  acute  general  peritonitis  that  almost  invariably  follows  perforation  may  be 
averted.  It  is  true  that  the  surgeon  who  makes  a  practice  of  operating  early 
in  perforation  will  occasionally  meet  with  a  case  in  which  no  perforation  can  be 
found,  in  which,  indeed,  no  perforation  has  occurred  ;  there  may  not  even  be 
peritonitis  ;  experience,  however,  has  shown  that,  in  the  majority  of  such  cases, 
little  or  no  harm  is  done. 

Another  important  factor  which  influences  the  prognosis  of  the  operation  for 
perforation  is  the  condition  of  the  patient  at  the  time  of  operation.  Those 
cases  do  best  in  which  the  patient  has  begun  to  convalesce  when  perforation  has 
taken  place  ;  and  the  outlook  is  worst  in  those  in  whom  it  occurs  during  the 
height  of  the  disease.  Still,  no  case  should  be  looked  upon  as  absolutely  hopeless  ; 
and  the  only  contra-indication  to  operation  is  a  moribund  state  of  the  patient. 

It  is  difficult  to  estimate  the  true  recovery-rate  after  laparotomy  for  perforation. 
Published  statistics  vary  from  about  8  to  50  per  cent,  but  it  is  certain  that 
more  instances  of  successful  than  of  unsuccessful  cases  are  reported.  The  series 
which  shows  the  best  results  is  that  published  by  G.  E.  Armstrong,  of  Montreal, 
in  which  there  were  78  cases  of  operation  with  24  recoveries,  a  recovery-rate  of 
30-7  per  cent,  an  extremely  good  result.  Of  107  consecutive  cases  operated  upon 
in  the  hospitals  of  the  Metropolitan  Asylums  Board  during  the  nine  years  1901 
to  1909,  8  recovered,  a  recovery-rate  of  7-5  per  cent.  Only  perforation  cases  are 
included  amongst  these  ;  Armstrong's  report  does  not  state  whether  perforation 
was  found  in  all  his  cases.  The  recovery  rate  is  higher  in  cases  of  operation  in 
which  no  perforation  has  occurred  than  in  those  in  which  it  has  occurred  ;   in 


TYPHUS    FEVER 


52^ 


the  latter  case  it  probably  does  not  exceed  20  per  cent.  But  even  the  7-5  rate 
quoted  above  is  better  than  the  i  per  cent  of  recovery  in  cases  of  perforation 
which  are  not  submitted  to  operation. 

Antityphoid  Inoculation. — -The  prognosis,  both  as  regards  protection  from  an 
attack,  and  recovery  wlien  attacked,  is  best  illustrated  by  the  figures  which  have 
recently  (May,  191 3)  been  published  by  the  Antityphoid  Committee  appointed 
bv  the  Army  Council  in  1904.  The  committee  investigated  the  histories  of 
19,314  soldiers,  whose  period  of  service  abroad,  in  places  where  they  were  likel}^ 
to  be  exposed  to  the  infection  of  the  disease,  averaged  twenty  months.  Of  these 
soldiers,  10,378  were  inoculated,  and  8,936  were  not.  The  incidence  of  typhoid 
amongst  the  non-inoculated  was  30-4  per  mille,  while  amongst  the  inoculated 
it  was  only  5-39  per  mille.  This  evidence  goes  to  show,  therefore,  that  inoculation 
is  of  great  value  as  a  protective  measure.  The  evidence  in  favour  of  its  worth 
as  an  agent  in  mitigating  an  attack  of  typhoid,  should  the  inoculated  person  be 
one  of  the  exceptions  to  the  general  rule,  is  not  so  strong.  The  committee 
investigated  the  histories  of  258  cases  of  typhoid  fever  amongst  these  soldiers. 
Of  these,  202  occurred  in  soldiers  who  had  not  been  inoculated,  and  56  in  those 
who  had  been  inoculated.  The  cases  were  divided  into  two  classes,  the  mild 
and  the  severe  (including  the  fatal).  Amongst  the  inoculated  men,  66- 1  per  cent 
belonged  to  the  mild  class,  and  33-9  to  the  severe  ;  while  amongst  the  non- 
inoculated,  29-3  per  cent  belonged  to  the  mild,  and  70-7  per  cent  to  the  severe. 
This  evidence,  so  far  as  it  goes,  is  in  favour  of  the  mitigating  effects  of  inoculation  ; 
but  the  number  of  cases  (258)  upon  which  this  conclusion  is  based  is  small. 

The  British  conclusions  have  been  confirmed  by  the  experience  of  antityphoid 
inoculation  on  a  large  scale  in  the  armies  of  the  United  States,  France,  and 
Germany,  especially  the  first  of  the  three.  Since  the  last  quarter  of  191 1,  anti- 
typhoid vaccination  has  been  made  compulsory  for  all  persons  in  the  military 
service  of  the  United  States  under  45  years  of  age.  The  practice  had  been  first 
employed  on  a  small  scale  in  1909,  and  was  voluntary  up  to  the  date  just 
mentioned.  Large  numbers  of  men  were  vaccinated  during  19 10  and  191 1. 
Before  1910  the  number  of  cases  of  typhoid  per  mille  of  the  mean  strength  varied 
from  3-1  in  1905  to  6-9  in  1902.     In  1910  it  was  2-4,  in  1911,  o-8,  and  in  1912  0-3. 

E.   W.  Goodall. 

TYPHUS  FEVER. — The  factors  which  must  chiefly  be  taken  into  account 
in  considering  the  prognosis  in  this  disease  are  :  (i)  The  age  ;  (2)  The  sex  ; 
(3)  The  habits  and  physical  condition  of  the  patient  ;  (4)  The  occurrence  of  com- 
plications ;   and  (5)  The  presence  of  certain  symptoms. 

I.  Age. — The  influence  of  age  is  well  illustrated  in  the  following  table 
compiled  by  Murchison,  which  shows  the  facts  in  respect  of  18,268  cases 
admitted  into  the  London  Fever  Hospital  during  the  23  years  1848  to  1870: — 


Fatality  according  to  Age. 


Age 

Fatality 

Age 

Fatality 

per  cent 

6-69 

per  cent 

Under  5  vears 

40    to    44 

30-79 

5    to     9 

3-59 

45    „     49 

42-54 

10    „    14 

2-28 

50    „     54 

49-62 

15    „    19 

4-46 

55     „    59 

53-96 

20    „    24 

10-33 

GO     „     G4 

60-25 

25    „    29 

15-17 

05     „     09 

75-53 

30    „    34 

20-55 

70     „     74 

72-62 

35    „    39 

25-92 

75  &  over 

85-71 

524  INDEX     OF     PROGNOSIS 

The  fatality  for  all  ages  was  18.92  per  cent. 

From  this  table  it  appears  that  the  fatality  is  moderate  below  twenty  years 
of  age,  and  is  indeed  low  in  the  age-group  ten  to  fourteen.  There  is  a  very 
considerable  increase  in  the  fatality  after  nineteen  years  of  age,  and  a  constant 
rise  for  every  decennium  (except  one)  after  that.  The  disease  is  extremely  fatal 
after  the  fiftieth  year. 

2.  Sex. — Murchison's  figures  go  to  show  that  on  the  whole  the  disease  is 
slightly  more  fatal  in  males  than  in  females,  the  fatality  being  19-67  per  cent  for 
the  one  sex  and  iSga  per  cent  for  the  other.  The  difference  is  most  marked 
at  ages  over  forty-five.  In  children  from  five  to  fourteen  the  fatality  is  rather 
higher  in  females  than  males. 

3.  Habits  and  Physical  Condition  of  Patient. — The  prognosis  is  unfavourable 
in  very  fat,  and  in  big,  muscular  persons,  in  those  of  intemperate  habits,  and  in 
those  who  are  the  subjects  of  chronic  diseases,  especially  of  the  kidneys. 

The  influence  of  pregnancy  is  shown  by  the  following  figures.  Of  107  pregnant 
women  who  came  under  Murchison's  care  at  the  I  ondon  Fever  Hospital,  49, 
or  45-8  per  cent,  aborted  about  the  tenth  to  fourteenth  day  of  the  disease  ;  9  of 
those  who  aborted  died,  but  the  remaining  98  all  survived.  From  these  figures 
it  appears  that  if  a  pregnant  woman  is  attacked  by  typhus,  she  is  very  likely 
to  abort  ;    and  that  if  she  does  so,  the  prognosis  in  her  case  becomes  worse. 

4.  Complications. — Murchison  stated  that,  in  his  experience,  death  in  patients 
under  fifteen  years  of  age  was  almost  always  due  to  some  severe  complication. 
Fortunately,  however,  complications  are  not  very  common  in  this  disease. 

Those  most  frequently  met  with  are  bronchitis  and  hypostatic  congestion  of  the 
lungs,  and  the  occurrence  of  the  latter  augments  the  gravity  of  the  prognosis. 
Laryngeal  inflammation  and  ulceration  is  a  rare  but  very  dangerous  complication. 
Suppurating  buboes  of  the  neck  (due  to  inflammation  of  the  parotid  and  sub- 
maxillary glands  and  the  surrounding  tissue)  are  relatively  common,  and  usually 
add  to  the  severity  of  the  attack. 

5.  Special  Symptoms. — The  following  are  unfavourable  symptoms  :  an 
abundant  rash  with  a  large  proportion  of  petechias  ;  cutaneous  haemorrhages  ; 
hypostatic  staining  of  the  skin  ;  cyanosis  ;  hurried  respiration ;  profuse 
perspiration  at  the  crisis  ;  a  pulse-rate  persistently  over  120,  especially  in  adults  ; 
pronounced  nervous  symptoms,  viz.,  sleeplessness  for  three  or  four  days,  delirium 
(especially  violent),  convulsions,  coma,  coma-vigil,  muscular  twitchings,  hiccough, 
contraction  of  pupils  to  a  pin-point ;  extreme  prostration  ;  a  notable  diminution  in 
the  amount  of  urine  ;  a  presentiment  of  death.  The  earlier  that  severe  cerebral 
symptoms  appear,  the  worse  the  prognosis.  It  is  a  favourable  sign  if  at  the  end 
of  the  first  week  the  temperature  drops  a  little,  and  still  more  so  if  it  does  not 
rise  again  before  the  crisis.  On  the  other  hand,  it  is  very  unfavourable  if  the 
temperature  keeps  steadily  high,  and  especially  if  it  rises  and  keeps  up  during 
the  second  week.  An  abrupt  rise  to  105°  F.  or  more,  just  before  the  crisis  is 
expected,  is  of  very  grave  omen.     Relapses  are  very  rare.  E.  W.  Goo  all. 

ULCERATIVE  ENDOCARDITIS. — {See  Endocarditis,  Ulcerative.) 

UREMIA. — The  prognosis  in  uraemia  must  always  be  guarded  ;  as  a  general 
rule,  it  is  very  grave.  Will  the  patient  survive  the  immediate  attack,  and  if  so, 
will  the  condition  recur  ? 

In  acute  nephritis,  when  the  patient  exhibits  all  the  phenomena  of  an  acute 
inflammatory  affection  of  the  kidneys,  with  partial  or  total  suppression  of  urine, 
death  may  result  from  an  initial  convulsion  ;  but  if  appropriate  measures  have 
been  effective  in  controlling  the  convulsions,  and  if  there  be  favourable  response 


URETHRAL     STRICTURE  525 

to  further  treatment,  no  more  nraemic  phenomena  may  develop,  and  the  ultimate 
prognosis  becomes  that  of  an  attack  of  acute  nephritis,  and  may  be  entirely 
favourable. 

In  chronic  nephritis,  whether  diffused  or  interstitial,  the  outlook  is  very 
serious.  In  the  convulsive  form,  death  may.  occur  early  from  failure  of  heart 
and  respiration  during  a  convulsion,  or  the  patient  may  die  comatose  after 
repeated  convulsions.  Even  if  temporary  improvement  takes  place  under 
treatment,  recurrence  of  uraemia  in  some  form  is  almost  certain  ;  and  the 
prognosis  is  very  grave,  the  fatal  issue  being,  as  a  rule,  only  a  question  of  weeks. 
When,  in  the  uraemia  of  chronic  nephritis,  the  onset  of  the  nervous  phenomena 
is  gradual  but  progressive,  the  prognosis  is  immediately  very  unfavourable. 
The  patient  is,  at  first,  naerely  dull  and  apathetic,  possibly  very  irritable  when 
roused  ;  the  kidney  function  is  very  deficient,  and  nitrogen  retention  is  present. 
In  a  few  days,  apathy  becomes  more  marked  ;  the  patient  is  difficult  to  rouse, 
and  passes  into  coma  ;  and  a  series  of  convulsions  may  precipitate  the  fatal  issue. 

Chronic  uraemia,  giving  rise  to  alimentary  symptoms,  also  justifies  a  very  grave 
prognosis.  The  chronic  nephritic  who  develops  a  dry,  furred,  cracked  tongue, 
persistent  vomiting,  and  possibly  diarrhoea,  is  in  a  critical  condition.  In  the 
dyspnoeic  form  of  uraemia,  a  fatal  issue  is  probable  ;  for  even  if  there  be  favour- 
able response  to  treatment,  the  kidney  inadequacy  is  marked,  and  recurrence 
of  uraemic  symptoms  is  almost  certain.  Other  phenomena  of  chronic  uraemia, 
such  as  persistent  headache,  amaurosis,  giddiness,  paralytic  phenomena,  and 
marked  insomnia,  are  all  grave  symptoms  which  point  to  pronounced  deficiency 
of  renal  function.  Francis  D.  Bnyd. 

URETERAL  CALCULUS. —  (See  Kidney  and  Ureter,  Calculus  of.) 

URETHRA,  RUPTURED. — The  immediate  mortality  of  ruptured  urethra 
depends  upon  two  factors  :  whether  extravasation  of  urine  has  taken  place,  and 
whether  there  are  other  grave  injuries,  such  as  fractured  pelvis.  Apart  from 
these,  there  is  no  great  danger  at  the  time. 

In  205  literature  cases,  uncomplicated  by  other  injuries,  Kaufmann  gives 
the  mortality  as  14  per  cent,  but  only  91  of  these  had  an  operation  within 
two  days  ;  of  these  latter,  9  per  cent  died.  The  deaths  were  mostly  due  to 
extravasation  ;    when  this  had  occurred,  36  per  cent  were  fatal. 

Martens  records  17  patients,  4  of  whom  had  fractured  pelvis,  who  were  operated 
on  at  once,  and  only  i  died.     This  would  be  more  in  accord  with  modern  practice. 

The  late  result  is  an  intractable  stricture.  In  the  older  surgery,  this  was  almost 
inevitable,  but  early  operation  does  much  to  ward  off  the  danger.  Rutherford 
reports  7  cases  treated  promptly  by  perineal  section  and  suturing  ;  5  remained 
free  from  stricture  for  years,  but  2  developed  a  narrowing.  Cabot  followed  5 
operation  cases  for  five  years,  no  stricture  following. 

Reference. — Thomson  Walker,  "  Ruptured  Urethra,"  BurghanVs  System  of 
Operative  Surgery.  A.  Rendle  Short. 

URETHRAL  STRICTURE. — One  of  the  axioms  of  the  older  surgery  was, 
"  Once  a  stricture,  always  a  stricture,"  and  it  has  even  been  suggested  by  a 
famous  surgeon  that  maxims  of  this  sort  should  be  framed  and  hung  up  to  adorn 
the  walls  of  hospital  wards  instead  of  the  texts  which  used  to  be  customary  ! 
To-day,  the  axiom  is  not  quite  true. 

Urethral  stricture  may  come  on  at  any  time  after  an  injury.  It  follows  gonor- 
rhoea at  one  of  two  periods,  the  first  about  two  to  four  years  after  the  attack, 
and  the  second  between  ten  and  sixteen  years  after.  Traumatic  strictures  are 
usually  worse  than  those  due  to  gonorrhoea. 


526  INDEX     OF     PROGNOSIS 

The  dangers  to  which  stricture  may  give  rise  depend  entirely  upon  the 
wiUingness  or  unwilhngness  of  the  patient  to  allow  proper  treatment.  Granted 
a  willing  patient,  stricture  need  never  cause  any  severe  symptoms,  except  in  old, 
neglected  cases  of  long  standing,  and  in  a  few  of  the  worst  of  the  traumatic 
strictures.  In  a  careless  or  timid  patient,  of  course,  a  long  string  of  troubles  may 
follow — attacks  of  retention,  peri-urethral  abscess,  perineal  fistula,  cystitis, 
epididymitis,  extravasation  of  urine,  rupture  of  the  bladder,  and  septic  pyelo- 
nephritis. Any  of  the  last  three  may  end  fatally.  A  patient  with  stricture  is  in 
danger  of  his  life  when  the  urine  is  very  foul,  when  rigors  and  fever  follow  attempts 
at  instrumentation,  or  when  the  bladder  remains  full  for  days.  Too  rapid  empty- 
ing, in  such  a  case,  will  often  lead  to  death  from  suppression.  Other  signs  of 
renal  infection  are  a  fall  in  the  urea  output,  wasting,  sweating,  thirst,  and  urinous 
odour  of  the  breath. 

Rupture  of  the  bladder  is  a  rare  event  in  acute  retention  ;  more  commonly  the 
membranous  urethra  gives  way,  leading  to  extravasation  of  urine. 

The  Effect  of  Treatment. — Rapid  or  continuous  dilatation,  the  routine  treat- 
ment, is  safe,  except  in  patients  whose  kidneys  are  seriously  involved,  but  it 
seldom,  if  ever,  cures  the  stricture,  and  must  be  repeated  at  intervals.  Sometimes, 
however,  it  takes  years  for  a  well-dilated  stricture  to  contract  down  sufficiently 
to  trouble  the  patient  much. 

Internal  urethrotomy  is  used  by  some  surgeons  where  others  would  dilate. 
The  mortality  is  about  i  per  cent  ;  of  1018  cases  treated  at  St.  Peter's  Hospital, 
0-78  per  cent  died,  and  of  4686  cases  collected  from  the  published  records  of 
various  surgeons,  i-i  per  cent  died.  In  the  great  majority  of  cases  well  followed 
through,  a  subsequent  dilatation  will  be  found  necessary  at  intervals,  but  in  rare 
cases  it  cures  outright.  On  the  other  hand,  a  few  patients  need  to  have  the 
operation  repeated. 

External  urethrotomy  seldom  cures  ;  it  is  now  usually  reserved  for  the  worst 
impassable  strictures,  and  subsequent  regular  dilatation  will  be  required.  Some- 
times the  operation  has  to  be  repeated.  The  mortality  in  100  cases  at  St. 
Peter's  Hospital  was  8  per  cent  (1895  to  1908),  and  older  figures  agree  well 
with  this. 

Excision  of  the  stricture  is  sometimes  a  perfect  cure,  but  the  results  are  not 
always  very  satisfactory  in  the  bad  cases  on  which  it  is  usually  tried.  Its  suc- 
cess greatly  depends  on  whether  the  urine  is  clean  or  foul.  Many  cases  of 
permanent  cure  are,  however,  quoted  by  Thomson  Walker  from  the  literature. 

Reference. — Thomson  Walker,  "  Stricture,"  Burghard's  System  of  Operative  Surgery. 

A.  Rendle  Short. 

UTERUS,  CANCER  OF. — Two  distinct  clinical  conditions  require  con- 
sideration under  this  head  :  (I)  Carcinoma  of  the  cervix,  in  which  the  results 
are  by  no  means  favourable,  the  cures  not  exceeding  25  per  cent  of  all  cases  ; 
and  (II)  Carcinoma  of  the  body — a  comparatively  rare  disease — where,  on  the 
other  hand,  the  results  may  be  said  to  be  good. 

I. — -Cancer    of    the    Cervix. 

It  is  necessary  to  consider  the  outlook  both  from  the  clinical  side  and  also 
in  relation  to  treatment. 

Now  the  prognosis  at  the  present  time  turns  not  only  upon  whether  the  case 
is  operable,  but  upon  whether  it  is  eradicable.  Even  its  more  enthusiastic 
advocates  do  not  advise  irradiation  in  all  cases,  although  in  certain  instances 
the  growth  has  disappeared  and  not  recurred  in  over  five  years. 

Prognosis  in  Relation  to  Clinical  Conditions. — The  following  points  present 
themselves    for    consideration    in    any    particular    case  :    (i)   The    size    of    the 


UTERUS,     CANCER     OF  527 

growth  ;  (2)   Its  extension  ;    (3)   The  glandular  enlargement  ;    (4)   The  condition 
of   the    growth  ;     (5)   The    general   state  of  the  patient. 

1 .  The  size  of  the  growth  is  not  per  se  a  very  good  criterion  as  to  operability  ; 
thus  a  comparatively  large  vaginal  growth  which  is  freely  movable  is  sometimes 
seen,  and  merely  indicates  a  slow-growing  type — more  especially  in  elderly 
patients  ;  while  a  comparatively  small  cervical  growth  may  yet  be  fixed.  It 
is  in  relation  to  the  degree  of  fixation  that  the  size  becomes  important. 

2.  Extension  of  the  growth  superficially  along  the  vaginal  surfaces  is  fortunately 
not  common,  but  when  present  it  usually  indicates  some  involvement  of  the 
wall  of  the  bladder  or  rectum,  so  that  such  cases  are  no  longer  suitable  for 
radical  operation.  Unfortunately,  too,  x  rays  and  radium,  when  applied  to 
these  cases,  frequently  give  rise  to  fistulous  openings. 

As  regards  thickening,  or  apparent  extension  into  the  pelvic  tissues  in  any 
direction,  one  must  be  careful  to  recognize  that  early  fixation  is  an  inflammatory 
process  of  a  chronic  nature,  representing  septic  absorption  from  the  growth,  and 
practically  always  preceding  an  extension  of  a  growth.  Clinically  there  is 
nothing  more  difficult  than  to  decide  whether  the  fixation  present,  be  it  to 
bladder,  rectum,  or  pelvic  wall,  is  inflammatory  or  malignant.  In  many  cases 
the  doubt  will  only  be  solved  by  an  exploratory  laparotomy  with  attempted 
removal  of  the  uterus. 

Thickening  in  the  broad  ligament,  if  well  marked  and  extending  right  out 
to  the  pelvic  wall,  is  likely  at  any  rate  to  contain  malignant  cells  in  the  portion 
adjacent  to  the  ureter,  and  therefore  more  reliance  is  to  be  placed  upon  con- 
solidation of  the  base  of  the  broad  ligaments.  However,  even  in  these  cases  the 
ureter  may  escape  invasion,  and  be  dissected  out  from  a  mass  of  growth  during 
operation.  It  is  probable  that  the  rhythmic  waves  of  contraction  serve  to 
protect  it  against  invasion.  The  prognosis  in  such  cases  is  not  good,  but  life 
may  be  prolonged  and  made  more  comfortable  by  operative  measures.  Farrar 
Cobb^  records  a  case  in  which  the  ureter  was  dug  out,  and  the  patient  was  alive 
and  free  from  recurrence  thirteen  years  later. 

3.  The  glandular  enlargement  is  only  occasionally  to  be  detected  on  examina- 
tion. As  a  rule  it  is  only  noted  during  operation,  and  then  as  more  commonly 
affecting  the  iliac  and  obturator  group  of  glands.  The  enlargement  of  the 
lymph  glands  must  not  be  taken  as  in  all  cases  indicating  malignant  metastasis. 
Thus,  some  enlargement  of  the  lymph  glands  is  present  in  90  per  cent  of  cases, 
but  evidence  of  malignancy,  even  after  microscopical  examination,  only  occurs 
in  15  to  20  per  cent  of  cases  operated  upon. 

4.  The  condition  of  the  growth  will  often  explain  the  cachexia.  Foul,  ulcerating 
growths,  both  by  reason  of  th^  associated  haemorrhage  and  the  septic  absorption, 
lower  the  resistance  of  the  patient,  so  that  the  shock  of  an  extended  operation 
may  prove  too  severe,  or  during  convalescence  a  cystitis  or  pyelitis  may 
determine  a  fatal  issue. 

Another  serious  risk  is  that  during  operation  the  peritoneum  or  operation 
area  may  become  infected  from  the  septic  cervical  growth,  and  so  cause  an 
acute  peritonitis  or  a  deep  pelvic  abscess.  Probably  at  least  20  per  cent  of  all 
deaths  are  to  be  attributed  to  this  cause. 

5.  The  general  condition  of  the  patient  is  often  too  readily  dismissed  with  a 
cursory  examination.  Thus,  until  recently  it  was  customary  to  regard  a 
cachectic  state  as  an  indication  of  advanced  growth,  while  another  patient,  fat 
and  healthy-looking,  was  considered  as  being  probably  in  a  less  advanced  con- 
dition. But  this  is  by  no  means  generally  true  ;  for  the  post-mortem  records 
of  cancer  institutions  show  that  not  more  than  50  per  cent  of  the  cases  of  cancer 
of  the  cervix  die  in  a  cachectic  state,  while  the  remainder  are  well  covered,  and 


52S  INDEX     OF     PROGNOSIS 

in  many  cases  even  fat.  Now  in  many  of  these  latter  cases  the  cause  of  deatli 
has  been  an  ascending  pyehtis  supervening  on  a  hydronephrosis  and  dilated 
ureter  or  ureters,  the  result  of  lateral  extension  of  the  growth.  It  is  evident 
that  cachexia  is  merely  an  accident  of  the  disease,  depending  upon  septic 
infection  of  the  growth.  Consequently,  in  judging  of  the  risk  of  operation  and 
the  chances  of  complete  cure,  a  careful  examination  is  required  which  shall 
include  investigation  as  to  the  cardiac  condition,  the  degree  of  anaemia,  and 
above  all,  the  renal  sufficiency. 

Further,  it  is  to  be  remembered  that  a  certain  degree  of  fatness  increases 
considerably  the  difficulty  of  complete  extirpation  and  in  consequence  the  risk 
of  injury  to  the  bladder  or  rectum,  and  also  renders  difficult  the  immediate 
arrest  of  haemorrhage  during  the  surgical  procedure. 

Nevertheless,  it  yet  remains  true,  that  in  cases  showing  well-marked  cachexia, 
with  septic  conditions  of  the  growths,  the  prognosis  is  not  good. 

Prognosis  apart  from  Treatment. — Apart  from  treatment,  the  duration  of 
life  is  usually  from  one  to  two  years.  Death  may  be  due  to  anaemia  and  cachexia, 
or  to  uraemia.  Sometimes  the  patient's  end  is  less  merciful,  and  the  scene  is 
only  terminated  after  months  of  pain,  with  bladder  and  rectal  troubles. 
Peritonitis  or  pulmonary  lesions  are  occasionally  met  with. 

Prognosis  in  Relation  to  Treatment. — The  results  of  treatment  by  radical 
operation  vary  within  certain  limits  according  to  the  selection  of  cases,  the 
extensive  nature  of  the  operation,  and  the  removal  of  lymphatic  tracts.  Speak- 
ing generally,  it  may  be  said  that  a  careful  selection  of  cases  will  show  a  high 
percentage  of  cures  amongst  those  operated  upon  ;  but  the  percentage  will  be 
low  if  all  the  cases  seen  are  included  ;  and  if  an  extensive  operation  is  per- 
formed, the  immediate  mortality  is  visually  high. 

As  to  operability,  Mayer^  in  a  large  series  of  cases  between  1902  and  1905,  con- 
demned 35  per  cent  as  inoperable.  This  65  per  cent  of  operability  represents 
a  fairly  average  figure  ;  but  some  idea  of  the  variation  may  be  gauged  by  the 
fact  that  many  surgeons  at  the  present  day  condemn  60  per  cent  as  inoperable. 
In  the  Massachusetts  General  Hospital  the  surgical  staff  rejected  230  cases  out 
of  367,  or  62-4  per  cent,  as  unfit  for  radical  operation  ;  and  Farrar  Cobb^  records 
that  he  operated  on  3  cases  condemned  as  inoperable  by  other  men,  with  the 
result  that  2  were  cured  and  the  third  died  of  recurrence  nearly  two  years 
later.  With  many  patients  it  may  be  said  that  it  is  impossible  to  decide  without 
an  exploratory  laparotomy  and  attempted  operation  whether  a  case  is  operable 
or  not  ;  and  as  an  instance,  Farrar  Cobb^  quotes  a  woman  alive  and  free  from 
growth  in  whom,  thirteen  years  before,  he  had  '  dug  '  the  ureter  out  of  the 
parametric  growth  during  the  course  of  operation.  The  percentage  of  opera- 
bility with  the  most  expert  surgeons  now  reaches  75  to  80  per  cent  of  all  cases. 

As  to  the  type  of  operation,  in  so  far  as  '  cures  '  are  concerned  (that  is,  cases 
free  from  recurrence  five  years  after  operation),  there  is  no  doubt  that  the 
radical  method  known  as  Wertheim's  hysterectomy  holds  precedence  of  place  ; 
unfortunately  the  immediate  mortahty  is  still  high,  although  tending  to  diminish. 
Operation  by  the  vaginal  route  is  largely  practised  by  Schauta.  We  subtend 
figures  comparing  the  results  of  Wertheim  and  Schauta,  from  which  it  will  be 
seen  that  the  operative  mortality  in  expert  hands  for  the  more  extended 
abdominal  operation  need  not  be  greater  than  that  for  the  vaginal  operation, 
while  the  end-results  are  much  better,  and  the  number  of  cases  which  are 
operable  by  the  abdominal  method  exceed  those  operable  by  the  vaginal  route. 

It  would  be  easy  to  multiply  statistics  in  which  the  literature  of  recent  years 
abounds  ;  but  the  figures  of  Wertheim  and  Schauta  represent  the  results  of 
two  specialists  employing  their  own  operative  procedures,  while  the  figures  of 


UTERUS,     CANCER    OF 


529 


Mayer,  who  used  both  methods,  are  more  representative  of  the  average  results 
to  be  expected.  It  must  be  remembered  that  the  two  methods  are  not  entirely- 
antagonistic  ;  for  in  certain  cases,  especially  in  fat  patients,  and  in  special 
instances  of  lesions  in  other  organs,  the  vaginal  route  offers  the  best  chance  of 
recovery  and  cure. 

Except  in  the  presence  of  exceedingly  early  growths,  hysterectomy  is  the 
only  operative  measure  to  be  adopted.  No  less  extensive  procedure  can  be 
justified  by  its  results. 


Results  of  Radical  Operation  for 

Cancer  of 

THE  Cervix 

Reporter 

Cases 

Died  from 
operation 

Recurred 

Operated  on 
over  five 
years  ago 

Percentage 
cured  after 
five  years 

Wertheim*  (abdominal)  - 
Schauta^  (vaginal) 
Mayer  (both) 

500 
498 
118 

percentage 

19-4* 

8-8 

20-9 

46 

or  38  9  per  cent 

250 

258 

34 

57-6 
37-9 
28-9 

30  per  cent  in  first  10  cases,  9  per  cent  in  last  175  cases. 


Palliative  Treatment  (including  x  rays,  radium,  and  mesothorium). 

Irradiation  cannot  as  yet  be  regarded  as  anything  but  a  palliative  measure, 
although  it  has  resulted  in  some  cures  in  isolated  instances.  The  treatment  is 
still  of  recent  date,  and  the  cases  are  comparatively  few  in  number. 

Bumm*  well  illustrates  the  effects  of  irradiation.  He  has  obtained  the  uterus 
in  five  cases  at  varying  periods  after  treatment.  In  each  case  some  focus  of 
disease  remained,  although  in  two  of  them  it  was  only  microscopically  detectable. 
In  the  majority  of  cases  the  results  depend  upon  the  type  of  growth — that  is  to 
say,  with  a  superficial  papillomatous  mass  a  very  excellent  result  will  be 
obtained,  simulating,  if  not  actually  producing,  a  cure ;  while  in  penetrating 
growths  the  external  appearance  of  the  cervix  and  the  relief  of  symptoms  will 
suggest  a  cure,  but  the  growth  proceeds  in  the  depths  and  in  the  lymph  tracts. 
The  best  results  will  be  obtained  where  the  cervix  is  curetted  before  applying 
the  radium,  so  as  to  get  greater  and  more  widespread  radiant  effect. 

A  disadvantage  of  the  treatment,  as  acknowledged  by  Degrais  and  Bellot,^ 
is  that  there  is  a  tendency  to  the  production  of  fistulas  when  the  growth  has 
already  invaded  the  vesical  or  rectal  wall.  Also  there  is  often  frequency  and 
pain  on  micturition,  or  rectal  tenesmus,  after  the  application. 

Finally,  it  must  be  said  that  in  inoperable  cases  radium  and  mesothoriun^ 
offer  very  good  palliative  treatment.  The  relief  of  symptoms  and  the  effects 
on  the  growth  itself  are  most  marked.  Unfortunately,  facilities  for  such  treat- 
ment are  limited  owing  to  the  expense. 

Of  other  palliative  measures  it  is  only  necessary  to  mention  two  procedures. 

The  use  of  the  cautery  is  often  most  beneficial  in  its  effect,  especially  with  the 
slow-growing  superficial  tumours.  It  helps  to  clear  the  growth,  and  formerly 
it  was  much  more  extensively  employed.  Wherever  possible,  however,  radium 
is  preferable. 

Ligation  of  the  internal  iliac  arteries  for  the  continuous  haemorrhage  has  in 
many  instances  caused  complete  relief  from  the  bleeding,  and  the  diminished 
blood-supply  has  seemed  occasionally  to  retard  the  growth. 

II. — Cancer  of  the  Body  of  the  Uterus. 

This  is  a  comparatively  rare  disease,  but  the  end-results  are  very  much 
superior  to  those  of  malignant  disease  of  the  cervix.     The  frequency  of  the 

34 


530  INDEX     OF     PROGNOSIS 

disease  may  be  gauged  from  the  fact  that  in  248  cases  of  uterine  growth  recorded 
by  Mayer,  only  37,  or  14-9  per  cent,  were  localized  in  the  body. 

Prognosis  from  the  Clinical  Aspect. — As  a  rule  there  is  little  in  this  respect 
upon  which  to  base  an  opinion  as  to  the  outlook.  In  the  first  place,  the  diagxiosis 
is  frequently  obscured  by  the  presence  of  fibromyomata,  to  which  are  accredited 
the  symptoms  of  the  disease  ;  in  the  next  place,  the  symptoms  and  the  know- 
ledge to  be  gained  by  bimanual  examination  together,  do  not  furnish  sufficient 
information  for  the  recognition  of  growth  in  the  majority  of  cases. 

Certain  features  may  be  taken  as  indicating  advanced  growth,  and  therefore 
limiting  the  chances  of  eradication.  The  size  of  the  uterus,  in  the  absence  of 
myomata,  is  a  distinct  index  of  the  extent  and  amount  of  the  neoplasm.  Again, 
a  mass  outside  the  uterus  may  indicate  a  metastatic  nodule  affecting  the 
appendages  or  pelvic  structures — but  it  is  not  to  be  invariably  taken  as  of  serious 
import ;  because,  in  perhaps  the  majority  of  cases  where  such  a  mass  exists,  it 
is  of  inflammatory  nature,  and  results  from  extension  of  the  septic  infection 
from  the  uterine  growth. 

Another  clinical  feature  of  some  importance  is  the  character  of  the  discharge. 
Excessive  bleeding,  through  the  resulting  ansemia,  obviously  detracts  from  the 
safety  of  undertaking  operation.  A  foul  discharge  is  still  more  important, 
both  on  account  of  the  septic  absorption  which  goes  on,  and  from  the  risk  of 
spreading  the  infection  during  operation.  Infection  of  the  peritoneum,  and 
of  the  operative  field  generally,  probably  accounts  for  the  greater  part  of  the 
operative  mortality. 

Prognosis  in  relation  to  Treatment. — The  results  of  treatment  are  those  of 
total  hysterectomy — no  other  rreasure  is  to  be  recommended.  It  frequently 
happens  that  a  small  growth  affecting  the  body  is  discovered  by  the  pathologist 
during  convalescence,  and  in  many  such  cases  a  subtotal  hysterectomy  only 
has  been  performed.  In  such  cases  it  must  be  decided  whether  the  margin  of 
healthy  tissue  between  the  growth  and  the  point  of  resection  is  sufficient  to 
justify  the  risk  of  leaving  the  cervix.  There  are  no  precise  figures  obtainable, 
but  from  general  experience  it  may  be  said  that  such  a  procedure  appears  com- 
paratively safe.  The  presence  of  large  fibroids  renders  the  vaginal  operation 
unsuitable  in  many  cases. 

Mayer,^  before  1906,  operated  on  26  cases  with  the  following  results  :  3  (11  per 
cent)  died  from  operation  ;  7  (26-9  per  cent)  showed  recurrence  ;  and  13  (52  per 
cent)  alive  and  well.  Doderlein^  quotes  Schauta  as  obtaining  83-3  per  cent 
of  cures,  and  states  that  the  chief  danger  is  infecting  the  stump  or  peritoneum 
with  either  septic  matter  or  new  growth,  Findley^  quotes  Kelly  as  recording 
81  per  cent  of  recoveries  in  16  cases.  From  all  of  which  it  will  be  seen  that  the 
results  of  treatment  in  cancer  of  the  body  of  the  uterus  are  relatively  good. 

References. — ^Boston  Med.  and  Surg.  Jour.  1914,  June,  861  et  seq.  ;  -Monats.  f. 
Geb.  ti.  Gyn.  1911,  xxxiii,  Hft.  6,  June  ;  ^Berl.  klin.  Woch.  1913,  Nov.  2086  ;  *Berl. 
klin.  Woch.  1914,  Feb.  193  ;  ^Canad.  Pract.  and  Rev.  1914,  June,  334  ;  ^Hegars  Beitr. 
ix,  Hft.  2  ;    Wiseases  of  Women,  zgi^,  680.  Bryden  Glendining. 

UTERUS,  FIBROIDS  OF.— The  prognosis  in  a  case  of  uterine  fibroids  is 
influenced  by  so  many  factors,  that  each  must  be  considered  as  regards  its 
peculiar  features.  The  subject  may  be  discussed  under  two  heads  :  (I)  The 
prognosis  from  the  clinical  point  of  view  ;  (II)  The  prognosis  in  relation  to 
treatment. 

I. — Prognosis    in    relation    to    Clinical    Features. 

Many  women  have  small  fibroid  nodules  of  the  uterus  which,  being  symptom- 
less, are  either  overlooked  or  only  discovered  by  accident  during  the  course  of 


UTERUS,     FIBROIDS     OF  531 

an  examination,  or  post  mortem.  It  is  estimated  that  20  to  30  per  cent  of 
women  who  reach  the  age  of  forty  years  show  fibroid  tumours  in  the  uterus. 

Risks  due  to  the  Presence  of  a  Fibroid. — The  possessor  of  a  fibroid  may  be 
said  to  incur  the  following  risks  in  varying  degree  :  (i)  Enlargement  of  the 
fibroid  ;  (2)  Degenerative  changes  in  the  tumour ;  (3)  Excessive  menstrual 
loss  ;  (4)  Extrusion  of  the  tumour  ;  (5)  Inflammatory  changes  ;  (6)  Pressure 
symptoms  ;  (7)  Increased  chance  of  carcinoma  of  the  body  of  the  uterus  ; 
(8)   Abnormal  conditions  in  pregnancy  and  labour. 

The  degree  in  which  these  risks  are  incurred  is  difficult  to  estimate.  Where 
the  patient  is  approaching  the  climacteric  and  the  tumour  is  small,  and  more 
particularly  if  it  be  subperitoneal  in  position,  the  chances  of  any  of  these  ill 
effects  are  slight.  When,  however,  the  patient  is  relatively  young  (under  forty 
years  of  age),  the  period  of  time  that  intervenes  before  the  menopause  con- 
siderably increases  the  liability  to  certain  of  these  risks. 

1.  Increase  in  size  of  a  tumour  is  usually  a  slow  process,  but  may  in  certain 
circumstances  be  rapid.  It  will  then  be  difficult  to  decide  whether  the  increased 
size  is  due  to  mere  rapidity  of  growth  or  to  degeneration. 

2.  Degenerative  changes  as  a  rule  cause  enlargement  of  the  tumour,  but  except 
in  the  case  of  '  red  degeneration  '  give  rise  to  little  anxiety.  Thus,  almost  the 
only  consequences  of  oedematous,  myxomatous,  or  cystic  degeneration  are  an 
increase  of  pressure  symptoms. 

'  Red  degeneration  '  is  a  more  serious  condition  Avhich,  from  the  peculiar 
symptoms  and  the  frequent  association  with  pregnancy,  must  often  be  a  source 
of  worry.  The  frequency  of  the  condition,  as  estimated  by  Noble^  in  2274 
cases,  is  4-7  per  cent;  but  this  figure  is  probably  high.  If  treated  surgically,  the 
results  are  uniformly  good.  If  untreated,  the  end-results  may  be  suppuration, 
or,  in  the  case  of  subperitoneal  tumours,  a  localized  peritonitis  with  adhesions 
to  bowel  or  omentum.     Eventually  many  of  the  tumours  become  calcareous. 

Sarcomatous  degeneration  of  a  fibroid,  according  to  Noble,^  occurs  in  about 
1-5  per  cent  of  all  the  tumours  removed  by  operation,  but  is  less  frequent  if  all 
cases  are  taken  into  account.  In  calcareous  degeneration  there  is  an  actual 
shrinkage  of  the  tumour,  and  therefore  a  relief  from  symptoms  may  often  be 
expected. 

In  general  it  may  be  said  that  the  liability  to  symptoms  arising  from 
degenerative  changes  are  in  direct  ratio  to  the  size  of  the  tumour  and  the  relative 
youth  of  the  patient. 

3.  The  chances  of  the  menstrual  loss  becoming  excessive  depend  almost  entirely 
on  the  situation  of  the  tumour.  Subperitoneal  fibroids,  because  they  do  not 
encroach  on  the  uterine  cavity,  have  but  little  tendency  this  way.  Even, 
however,  when  the  tumour  felt  is  obviously  in  this  situation,  it  is  impossible 
to  exclude  the  chance  of  some  smaller  tumour  being  present  more  nearly  in 
relation  with  the  endometrium.  Indeed,  since  it  is  rare  to  find  a  single  tumour, 
it  may  be  argued  that  where  one  large  mass  can  be  felt — whatever  its  position — 
it  is  pretty  certain  that  one  or  more  other  tumours  exist,  too  small  for  recognition, 
but  which,  by  their  possibility  of  subsequent  growth,  render  the  supervention  of 
jnenorrhagia  not  unlikely,  although  at  the  moment  no  such  symptom  may  be 
present.  The  haemorrhage  due  to  a  fibroid  is  rarely  directly  fatal  nowadays, 
because  the  case  comes  to  operation  before  such  a  disaster  has  time  to  occur. 
It  does  occasionally  still  happen,  however. 

Indirectly,  the  severe  mcnorrhagia  is  responsible  not  only  for  many  of  the 
fatalities,  but  also  for  many  of  the  tardy  convalescences,  that  follow  operation. 
The  intense  anaemia  induces  a  generally  enfeebled  state  of  the  tissues,  and 
particularly  of  the   heart   muscle,    with  consequent  cardiac  dilatation.      It   is 


532  INDEX     OF     PROGNOSIS 

amongst  this  class  of  patients  that  most  of  the  deaths  following  the  removal 
of  fibroids  are  found,  the  fatal  result  being  due  to  exhaustion,  sudden  cardiac 
failure,  or  pulmonary  embolism.  Further,  the  anaemic  state  of  the  patient 
tends  to  favour  the  occurrence  of  venous  thrombosis,  with  its  attendant  risk 
of  pulmonary  embolism.  Post-operative  femoral  thrombosis,  when  it  occurs, 
is  nearly  always  seen  in  intensely  anaemic  patients.  Apart  from  the  risk 
of  pulmonary  embolism,  this  complication  delays  recovery  for  from  six  weeks 
to  three  months.     The  left  leg  is  the  one  usually  affected. 

4.  Extrusion  of  a  fibroid  may  take  place  in  one  of  two  ways.  In  the  first, 
a  submucous  tumour  practically  becomes  polypoid  and  is  pushed  through  the 
cervix,  a  process  associated  with  smart  haemorrhage  and  sometimes  with  pain. 
In  the  second,  a  sessile  submucous  tumour  becomes  inflamed  and  sloughs,  the 
capsule  of  endometrium  covering  it  gives  way,  and  the  mass,  often  in  a  pul- 
taceous  and  stinking  condition,  is  forced  out  of  the  uterus.  This  process  is  one 
associated  with  symptoms  of  more  or  less  acute  sepsis,  and  is  one  of  considerable 
danger. 

The  liability  to  these  happenings  is  obviously  dependent  upon  the  situation 
of  the  tumour  in  the  first  instance.  Further,  they  are  comparatively  rare 
below  forty  years  of  age.  The  consequences  are  hemorrhage  and  septic  absorp- 
tion ;  but  the  chief  danger  arises  when  such  tumours  are  removed  by  the 
abdomen,  when  the  chance  of  infecting  the  peritoneum  is  serious. 

5.  The  charices  of  inflammatory  changes — or  changes  leading  to  inflammation — 
taking  place  in  or  around  the  tumour  are  definite,  for  in  a  considerable  propor- 
tion of  the  cases  operated  on  such  an  event  has  occurred.  Thus,  salpingitis 
is  quite  commonly  found,  usually  of  the  sclerotic  or  hydrosalpingitic  variety, 
but  occasionally  the  tubes  contain  pus.  Another  not  uncommon  condition  to 
find  is  hematosalpinx,  usually  on  both  sides.  The  liability  to  salpingitis  is 
increased  if  the  patient  has  undergone  intra-uterine  treatment,  such  as  curettage, 
electrolysis,  ionization,  and  so  forth,  and  also  if  pregnancy  occurs,  since  fibroids 
increase  the  chances  of  sepsis  during  the  puerperium. 

Pedunculated  fibroids  may  undergo  axial  rotation,  but  this  is  a  much  less 
common  event  than  is  the  case  with  ovarian  cysts. 

6.  The  chances  of  pressure  symptoms  developing  depend  upon  the  situation  of 
the  tumour.  When  it  is  low  down,  and  especially  when  it  is  growing  from  the 
supravaginal  cervix,  such  symptoms  are  very  common  ;  when  it  is  situated  in 
the  upper  part  of  the  uterus  they  are  less  likely. 

Most  patients  with  fibroids  in  the  uterus  experience  more  or  less  frequency  of 
micturition.  Cervical  fibroids,  if  impacted  in  the  pelvis,  cause  retention  of 
urine.  Similarly,  a  fundal  tumour  may  cause  the  uterus  to  retrovert  and  become 
fixed  under  the  promontory,  with  a  like  result.  The  ureters,  strangely  enough, 
are  rarely  pressed  upon. 

Acute  intestinal  obstruction  may  be  caused  by  a  fibroid — rarely  by  simple 
impaction  in  the  pelvis,  much  more  commonly  by  inflammatory  adhesions. 

7.  The  presence  of  a  fibromyoma  in  the  uterus  undoubtedly  predisposes  to 
carcinoma  developing  in  the  corporeal  endometrium.  It  is  found  that  carcinoma 
of  the  corpus  is  associated  with  fibroids  in  4  per  cent  of  cases.  The  exact  degree 
of  risk  that  a  patient  runs  in  this  connection  is  impossible  to  estimate,  and  it 
must  be  remembered  that  corporeal  carcinoma  is  not  a  common  disease  under 
any  circumstances.  The  possibility  of  this  change  supervening  should  always 
be  borne  in  mind  when  the  regular  periodic  haemorrhage  of  a  fibroid  uterus 
begins  to  give  place  to  irregular  or  constant  loss. 

Carcinoma  of  the  cervix  is  rarely  (0-7  per  cent  of  all  cases)  associated Jwith 
fibromyomata,  since  the  latter  are  common  in  sterile  women  and  the  former 
is  more  particularly  associated  with  fertility. 


UTERUS,    FIBROIDS    OF  533 

8.  With  regard  to  pregnancy  and  labour,  the  question  of  fertility  in  relation 
to  fibroids  constantly  calls  for  decision.  These  tumours  are  frequently  associ- 
ated with  sterility.  Findley^  states  that  30  per  cent  of  myomatous  women  are 
sterile,  as  opposed  to  a  10  per  cent  rate  for  the  female  population  in  general. 
The  sterility  may  be  due  to  the  fibroid  itself  obstructing  the  meeting  of  sperm 
and  germ,  or  to  some  endometrial  change. 

If  conception  occurs,  there  is  an  increased  chance  of  miscarriage,  but  not  to 
the  extent  that  might  be  thought,  because  in  such  cases  the  fibroids  are  often 
subperitoneal  in  position  and  do  not  interfere  with  the  uterine  development. 

Pregnancy  tends  to  an  increase  in  size,  often  more  apparent  than  real,  of  the 
fibroid  tumour.  There  is  also  an  increased  liability  of  the  tumour  to  undergo 
degeneration  and  softening.  Allusion  has  already  been  made  to  the  frequent 
association  of  '  red  degeneration,'  which  may  require  surgical  treatment. 

The  risks  during  labour  depend  on  the  situation  of  the  tumour — masses  low 
down  will  obstruct  delivery  and  necessitate  surgical  measures,  but  when  super- 
ficial and  growing  from  the  upper  part  of  the  uterus,  no  ill  results  may  follow. 
There  is,  however,  an  increased  risk  of  post-partum  haemorrhage  in  all  cases. 

During  the  puerperium  a  fibroid  may  inflame,  necrose,  or  be  extruded.  These 
events  are  fraught  with  grave  risks  to  the  patient.  If  in  the  course  of  a  difficult 
delivery  the  tumour  has  been  bruised,  septic  necrosis  is  likely  to  follow. 

It  will  thus  be  seen  that  the  possession  of  a  fibroid  tumour  very  definitely 
increases  the  risks  of  child-bearing.  On  the  other  hand,  the  various  complica- 
tions that  may  arise  in  the  course  of  pregnancy,  labour,  and  the  puerperium 
can  in  most  cases  be  foreseen,  or  at  all  events  watched  for,  and  if  treated  early 
can  be  successfully  overcome. 

II.    Prognosis    in    relation    to    Treatment. 

Operative  Treatment. — This  is  the  course  to  be  advised  in  the  vast  majority 
of  fibroids  giving  rise  to  symptoms,  for  not  only  is  it  the  only  certain  method 
of  cure,  but  it  is  also  the  quickest,  and  in  the  long  run  the  least  expensive. 

Abdominal  hysterectomy  will  be  first  of  all  referred  to.  The  surgery  of  these 
tumours  has  been  so  greatly  improved  of  recent  years  that  the  average  mortality 
of  the  most  radical  procedure — viz.,  hysterectomy — is  probably  not  much  over 
I  per  cent  in  expert  hands,  no  greater  in  fact  than  that  of  appendicectomy  in 
the  quiescent  period. 

Each  case  must,  however,  be  considered  on  its  own  merits.  Hysterectomy 
is,  in  many  cases,  a  perfectly  straightforward  operation,  one  that  may  be  per- 
formed '  by  the  book  '  even  by  an  operator  of  very  little  experience.  But  on 
the  other  hand,  it  may  be  an  extremely  formidable  undertaking,  in  which  the 
question  as  to  whether  an  expert  or  a  tyro  is  to  perform  it  makes  all  the 
difference  in  the  prognosis.  No  one  who  is  not  fully  competent  to  carry  through 
successfully  the  most  difficult  case  should  undertake  this  class  of  surgery  at 
all,  for  it  is  often  impossible  to  gauge  beforehand  the  degree  of  difficulty  that 
will  be  met  with. 

The  operation  of  subtotal  hysterectomy — the  cervix  being  left  behind — is 
the  one  most  generally  applicable  to  cases  of  fibroids.  It  is  considerably  easier 
than  the  total  operation,  especially  in  the  more  complicated  cases,  and  if  the 
cervix  is  healthy  there  is  no  good  reason  to  remove  it. 

The  total  operation  should  be  reserved  for  special  cases  where  the  cervix  is 
unhealthy,  the  uterus  above  it  carcinomatous,  or  where  vaginal  drainage  is 
desired. 

In  either  operation  the  ovaries  should  be  conserved  if  they  are  healthy  ;  or 
if  this  is  not  possible,  then  one,  or  at  least  part  of  one,  should  be  left  behind. 


534  INDEX     OF     PROGNOSIS 

The  ovarian  function  continues  unimpaired  after  hysterectomy,  and  in  this 
regard  the  patient  is  no  worse  off  than  other  women. 

Patients  often  ask  what  effect  removal  of  the  uterus  will  have  on  their  nervous 
system  and  upon  sex  feelings  and  intercourse  in  particular.  The  answer  is 
that  the  operation  leaves  them  in  this  respect  unaltered.  Child-bearing  is  of 
course  impossible,  but  with  this  restriction  marriage  is  able  to  be  entered  upon 
without  any  drawback. 

The  risks  of  the  operation  are  of  course  increased  if  the  fibroid  be  complicated 
by  one  or  other  of  the  superposed  conditions  that  have  been  referred  to.  Of 
these,  septic  infection  and  necrosis  are  the  most  dangerous. 

In  the  case  of  a  patient  very  ill  with  a  fibroid  tumour,  the  objection  to  an 
operation  is  frequently  made  that  she  is  too  weak  to  undergo  it.  The  repty  is 
that  she  will  not  get  stronger  by  waiting,  and  that  the  difficulties  of  the  operation 
will  certainly  increase. 

In  conclusion,  as  illustrative  of  the  results  of  hysterectomy,  we  quote  the 
returns  for  1912  and  1913  of  the  Chelsea  Hospital  for  Women,-  representing  all 
the  cases  operated  upon  by  the  various  members  of  the  staff  :— 

Total  hysterectomy  for  myomata  :  21  cases,  no  deaths.  Subtotal  hyster- 
ectomy for  fibroids  (with  or  without  complications  such  as  diseased  appendage 
or  appendages,  ovarian  cysts,  etc.)  :    203  cases,  i  death. 

These  figures  represent  the  result  in  expert  hands  under  good  conditions. 
They  are  therefore  good  ;  but  they  are  the  results  of  operations  by  all  the 
members  of  the  staff,  and  may  in  consequence  be  taken  as  an  index  of  what  is 
easily  realizable. 

Myomectomy,  with  the  conservation  of  the  uterus,  offers  an  alternative  treat- 
ment in  certain  instances.  The  object  is  to  allow  if  possible  for  the  supervention 
of  pregnancy,  and  to  maintain  the  menstrual  function.  With  regard  to  the 
latter  point  it  may  be  said  that,  as  in  many  cases  of  myomata  the  patient  seeks 
treatment  from  the  surgeon  for  the  cure  of  excessive  menstrual  loss,  m3^omectomy 
in  many  instances  does  not  offer  a  complete  cure,  because  the  operation  leaves 
behind  a  much  hypertrophied  uterus  from  which  a  continuance  of  the  menor- 
rhagic  symptoms  is  not  unlikely.  The  prospects  of  future  pregnancy  would 
not  appear  to  be  great,  as  it  is  generally  believed  that  not  more  than  10  per 
cent  of  these  patients  subsequently  conceive.  Reliable  statistics  are,  however, 
unknown  to  us. 

It  is  likely,  nevertheless,  that  in  competition  with  radium,  myomectomy 
will  be  more  extensively  performed.  The  fact  remains,  however,  that  myo- 
mectomy is  limited  to  special  cases  where  the  tumours  are  not  abundant,  where 
menorrhagia  is  not  marked,  and  where  the  uterus  itself  is  not  hypertrophied. 

The  mortality  in  expert  hands  is  low.  W.  Mayo^  reports  i  death  in  157  cases 
of  myomectomy  in  the  last  decade. 

Vaginal  operations  are  sometimes  called  for.  Vaginal  hj^sterectomy  is  now 
seldom  employed  ;    no  radical  operation  by  this  route  is  advisable. 

The  removal  of  a  fibroid  polypus  is  a  simple  procedure,  without  practical  risk. 

Large  tumours  are  sometimes  best  removed  in  this  way,  especially  sloughing 
submucous  fibroids,  for  in  such  cases  the  profound  sepsis  makes  an  abdominal 
operation  undesirable  if  it  can  be  avoided. 

Curettage  as  a  cure  for  fibroid  menorrhagia  is  not  to  be  commended.  It 
carries  with  it  a  definite  risk  of  infection  of  the  tumour,  and  in  any  case  its 
effect  is  merely  temporary. 

Irradiation. — Recently  many  cases  of  fibroids  have  been  treated  by  x  rays 
or  by  radium,  and  good  results  have  been  claimed ;  but  sufficient  time  has  not 
elapsed  to  prove  their  permanence. 


UTERUS,     RUPTURE     OF  535 

There  are  certain  classes  of  cases  in  which  such  treatment  is  absolutely  contra- 
indicated — namely,  where  the  nature  of  the  tumour  suspected  of  being  a  fibroid 
is  not  certainly  known,  where  inflammatory^  signs,  or  signs  of  incipient  malignant 
disease,  are  present,  and  where  urgent  symptoms  due  to  pressure  or  degeneration 
have  declared  themselves. 

Irradiation  seems  to  act  by  destroying  the  function  of  the  ovaries  and. 
inducing  a  premature  menopause,  with  its  attendant  train  of  symptoms.  As 
such,  it  is  undesirable  in  relatively  young  patients.  The  treatment  takes  some 
weeks  to  carry  through,  and  though  menorrhagia  would  appear  to  be  cured  in 
many  of  the  cases,  and  the  tumour  made  to  shrink  in  a  lesser  proportion, 
absolute  disappearance  of  the  mass  does  not  occur.  The  patient,  therefore, 
cannot  be  considered  as  cured. 

In  the  light  of  our  present  knowledge,  therefore,  the  treatment  by  irradiation 
must  be  considered  quite  inferior  to  the  surgical  removal  of  the  tum.our. 

Having  regard  to  the  interest  now  attaching  to  this  form  of  treatment,  it 
will  be  well  to  give  some  figures  of  results  taken  from  the  recent  literature  of  the 
subject. 

As  regards  x  rays,  Birdsall*  quotes  the  following  statistics  collected  by 
Holding  :  Of  667  cases,  56  per  cent  were  considered  cured,  31  per  cent  improved, 
II  per  cent  unimproved,  and  2-03  per  cent  died.  Marck^  gives  the  following 
figures  :  Of  16  cases,  9  were  cured,  or  56  per  cent ;  4  were  better,  or  25  per 
cent ;  3  were  unimproved,  or  19  per  cent ;  only  in  3  cases  was  a  diminution  in 
volume  recognized. 

As  regards  radium,  Kelly  and  Bumam^  treated  21  cases  in  this  way  :  In 
2  the  tumours  disappeared,  while  the  menstrual  periods  persisted  regularly  ;  in 
I  the  treatment  failed,  and  operation  was  undertaken  ;  in  i  inflammation 
occurred,  and  an  abscess  formed  ;  in  6  the  tumour  apparently  disappeared  ; 
and  in  13  the  tumour  was  reduced  in  size. 

Palliative  and  Expectant  Treatment. — This  is  based  on  the  chance  of  the 
tumour  shrinking  in  size  and  ceasing  to  give  rise  to  symptoms  after  the  meno- 
pause.    The  likelihood  is  shown  to  be  much  less  than  was  formerly  supposed. 

Fibroids  prolong  menstrual  life,  and  the  menopause  is  frequently  not  attained 
till  the  patient  is  well  over  fifty.  After  the  cessation  of  the  periods,  the  tumour 
does  slowly  shrink  in  a  fair  proportion  of  cases ;  but  in  others  it  continues  to 
grow,  or  remains  stationary.  So  long  as  it  is  present,  the  possibility  remains 
of  some  complication  supervening,  and  operations  on  elderly  women  have 
commonly  to  be  performed  on  this  account.  The  period  of  the  menopause  and 
after  would  indeed  appear  to  be  that  in  which  degeneration,  inflammation, 
and  malignant  change  are  most  common. 

The  mortalitj^  in  expectant  treatment  is  estimated  at  30  per  cent. 

References. — ^Findley,  Diseases  of  Women,  1914,  586  ;  ^Chelsea  Hospital  for  Women, 
42nd  and  43rd  Annual  Reports  ;  ^Surg.  Gyn.  and  Obst.  1911,  Feb.  ;  *Med.  Rec.  1914, 
May,  892  ;    '"Wien.  klin.Woch.  1914,  May,  745  ;  ^Jour.  Amer.  Med.  Assoc.  i9i4,Aug.22. 

Bryden  Glendining. 

UTERUS,  RUPTURE  OF. — The  outlook  in  rupture  of  the  uterus  must  still 
be  regarded  as  very  serious,  as  less  than  one  in  four  cases  recovers  at  the  present 
day.  Recent  figures,  however,  show  a  vast  improvement  in  results,  the  mor- 
tality being  reduced  by  half,  and  this  improvement  is  largely  due  to  a  revolution 
in  treatment. 

It  is  important  to  bear  in  mind  that,  although  the  gravity  of  uterine  rupture 
is  thought  to  be  due  to  the  ensuing  haemorrhage,  yet  it  is  rarely  that  such 
haemorrhage  is  sufficient  to  cause  immediate  death.  Thus,  the  maiority  of 
deaths  occur  between  three  and  twelve  hours  after  the  time  of  rupture — when 


536  INDEX     OF     PROGNOSIS 

the  shock  has  to  some  degree  passed  off  and  further  oozing  occurs.  Haemor- 
rhage proved  fatal  in  42-8  per  cent  of  the  cases  occurring  in  the  Moscow 
Maternity  Hospital  in  a  series  collected  by  Ivanoff.^  In  at  least  50  per  cent 
of  cases,  a  dangerous  haemorrhage  occurs,  but  it  is  not  necessarily  tatal. 

On  the  other  hand,  the  part  played  by  septic  infection  in  these  cases  is  very 
considerable  ;  it  is  estimated  that  37  per  cent,  or  according  to  Eden^  50  per 
cent,  succumb  from  this  cause. 

It  is  thus  seen  that  hsemorrhage  and  sepsis  are  much  more  serious  than 
shock,  which  accounts  for  a  small  number  of  deaths. 

Although  the  tendency  of  the  present  day  is  to  ignore  to  some  extent  the 
division  into  complete  and  incomplete  rupture  of  the  uterus  as  regards  method 
of  treatment,  yet  it  will  be  well  to  retain  the  grouping  when  considering  the 
prognosis. 

Incomplete  Rupture. — The  prognosis  is  influenced  by  (i)  The  extent  of  the 
rupture  ;  (2)  The  stage  of  parturition  ;  and  (3)  The  conditions  under  which  it 
has  occurred. 

1.  The  Extent  of  the  Rupture. — Ruptures  involving  only  the  lower  segment 
present  a  much  better  outlook,  in  that  the  haemorrhage  is  readily  controlled  by 
packing,  and  there  is  no  risk  of  internal  bleeding.  The  chances  of  septic 
complications  are  also  considerably  less.  On  the  other  hand,  where  the  rupture 
extends  well  up  the  uterus  to  the  peritoneal  reflection,  the  condition  is,  speak- 
ing generally,  just  as  serious  as  in  the  complete  variety,  and  the  prognosis 
differs  little  from  what  obtains  in  that  condition,  except  that  direct  peritoneal 
infection  is  excluded.  The  haemorrhage  in  these  cases  is  often  subperitoneal, 
and  has  been  known  to  extend  extraperitoneally  as  high  as  the  kidney. 
Klein^  collected  30  cases  in  which  extraperitoneal  haemorrhage  occurred  in 
this  way,  with  a  mortality  of  70  per  cent. 

In  many  of  the  more  extensive  ruptures  of  the  uterus  it  has  been  found  that 
considerable  difficulty  was  experienced  in  recognizing,  by  digital  examination, 
whether  the  peritoneum  was  actually  torn  or  not. 

2.  The  Stage  of  Parturition. — In  ruptures  occurring  before  the  final  expulsion 
of  the  child,  or  while  the  placenta  yet  remains  undelivered,  the  expulsion  of 
the  afterbirth  will  certainly  increase  the  risk  of  further  haemorrhage  ;  and 
should  manual  removal  be  necessary,  the  manipulations  may  almost  un- 
avoidably increase  the  extent  of  the  tear. 

3.  The  Conditions  under  which  Rupture  occurs. — These  are  important  in  many 
ways.  For  instance,  rupture  of  the  uterus  frequently  occurs  while  turning 
the  child  for  some  malpresentation,  such  as  a  prolapsed  arm.  In  this  instance 
the  presenting  part  will  have  been  returned  to  the  uterus,  and  the  operator's 
hand  will  also  have  been  introduced — under  such  circumstances  it  is  difficult  to 
exclude  the  risk  of  sepsis. 

Again,  in  cases  where  the  rupture  is  spontaneous,  which  is  rare  in  the  slighter 
incomplete  forms,  the  outlook  is  good,  once  the  haemorrhage  has  stopped.  In 
these  cases,  equally  good  results  are  claimed  both  by  those  who  favour  douching 
with  drainage,  and  by  those  who  insist  that  packing  with  gauze  is  essential. 

Complete  Rupture  and  Large  Incomplete  Ruptures. — The  factors  which 
enter  into  consideration  in  these  cases  are  somewhat  different,  and  may  be 
considered  under  the  following  headings:  (i)  The  amount  of  haemorrhage; 
(2)  The  facilities  for  operative  procedure  ;    (3)  The  treatment  adopted. 

I.  The  Amount  of  Hemorrhage. — This  must  to  a  large  extent  be  judged  by 
the  condition  of  the  patient.  It  is  to  be  remembered  that  the  bleeding  is 
almost  entirely  intraperitoneal — except  in  the  incomplete  variety,  where  it  is 
largely  extraperitoneal.     A  factor  which  seriously  complicates  the  problem  in 


UTERUS.     RUPTURE     OF  537 


these  cases  is  the  estimation  of  the  accompanying  shock.  It  will  be  found 
that  blanching  is  of  more  value  as  an  indication  of  the  amount  of  haemorrhage 
than  the  actual  state  of  the  pulse.  The  most  reliable  information  is  to  be 
gained  from  a  consideration  of  the  condition  of  affairs  in  the  pelvis.  In  a 
uterus  from  which  both  the  foetus  and  the  placenta  are  delivered,  either 
externally  or  into  the  peritoneal  cavity,  and  which  has  contracted  down  firmly, 
the  amount  of  bleeding  is  not  immediately  dangerous.  On  the  other  hand, 
in  a  uterus  still  occupied  by  the  placenta,  the  haemorrhage  must  always  be 
serious  ;  it  is  to  be  remembered  that  the  more  serious  bleeding  is  the  secondary 
haemorrhage  or  oozing  that  takes  place  as  shock  passes  off.  Some  idea  of  the 
effect  of  haemorrhage  is  seen  in  IvanofE's  series  of  124  cases  in  the  Moscow 
Maternity  Hospital,  where  haemorrhage  proved  fatal  in  42-8  per  cent  ;  while 
in  the  Bucharest  Hospital  it  was  fatal  in  24  per  cent. 

2.  The  Facilities  for  Operative  Procedure. — While  there  are  a  certain  number 
of  cases  in  which  the  haemorrhage  is  rapidly  fatal,  yet,  if  in  the  remainder 
effective  surgical  measures  could  be  adopted  within  a  short  time,  the  mortahty 
would  be  small.  The  necessity  in  the  majority  of  cases  of  waiting  until 
operation  can  be  undertaken,  or  of  transport  to  a  hospital,  has  in  many 
instances  been  disastrous. 

Further,  while  to  the  experienced  gynaecologist  there  is  nothing  inherently 
difficult  in  the  operative  treatment  of  rupture ;  to  any  one  not  so  practised  the 
altered  relationships  of  the  parturient  uterus  increase  considerably  the  operative 
risks,  both  by  reason  of  the  possible  damage  to  neighbouring  structures  and 
by  the  time  lost  in  orientation.  Therefore  the  absence  of  operative  facilities 
and  of  an  experienced  obstetric  surgeon  militate  against  the  chance  of  recovery. 

3.  The  Treatment  Adopted. — The  results  of  operative  treatment  are  so  very 
much  better  than  those  of  any  expectant  method,  that  the  latter  can  only  be 
justified  in  very  exceptional  circumstances. 

Of  the  operative  procedures,  the  question  resolves  itself  into  deciding 
whether  the  better  results  are  to  be  obtained  by  securing  the  bleeding  point 
and  repairing  the  rent,  or  by  hysterectomy.  It  would  be  thought  that  the 
simpler  procedure  would  give  the  better  results  ;  but  when  it  is  remembered 
that  somewhere  about  45  per  cent  of  cases  die  of  sepsis,  the  risks  that  are  run  in 
leaving  the  uterus  behind  are  considerable.  A  more  remote  effect  is  sometimes 
seen  in  the  subsequent  history — the  liability  to  a  second  rupture.  Tarnier^ 
has  collected  15  cases  in  which  a  second  rupture  occurred,  with  a  mortality  of 
33  per  cent.  Again,  it  has  happened  in  a  few  instances  that,  owing  to  difficulty 
in  suturing  the  rupture,  further  bleeding  has  been  possible.  On  the  other 
hand,  in  a  perfectly  clean  case  where  fertility  is  desired  and  the  conditions 
are  favourable,  the  simple  repair  of  the  rent  offers  a  very  good  prognosis. 

However,  hysterectomy,  and  especially  abdominal  hysterectomy,  will  offer 
the  best  chance  in  the  majority  of  cases.  Its  efficacy,  the  direct  control  of 
haemorrhage  which  is  obtained,  and  the  elimination  to  a  great  extent  of  serious 
septic  complications,  outweigh  the  loss  of  the  uterus  and  the  slightly  greater 
shock  in  most  cases.  Vaginal  hysterectomy  has  not  been  performed  extensively, 
but  Kolomenkin^  has  collected  3  cases  with  i  death,  and  Klein^  7  cases  with 
4  deaths. 

In  conclusion,  we  give  a  few  general  figures  : — 

Some  of  the  most  reliable  are  those  collected  by  Kolomenkin,^  which  represent 
cases  treated  in  special  institutes  only — where  the  conditions  may  be  said  to  have 
been  most  favourable.  Of  140  cases,  97  were  treated  conservatively,  with  a 
mortality  of  61  per  cent  ;  33  were  treated  by  hysterectomy,  with  a  mortality 
of  36  per  cent. 


538  INDEX     OF     PROGNOSIS 

Tarnier*  between  1885  and  1897  treated  11  cases  by  packing,  douching,  etc.  : 
10  died.  Between  1897  and  1902  he  treated  12  cases  :  6  died  before  operation 
could  be  done,  3  died  after  operation,  3  were  cured. 

Blacker*  treated  8  cases  :  3  were  operated  on — all  recovered  ;  2  did  not 
admit  of  treatment — both  died  ;  3  were  plugged  with  gauze — 2  died,  i 
recovered. 

References. — ^Ann.  de  Gyn.  et  d'Obst.  1904,  Ixi,  449  ;  ^Proc.Roy.  Soc.  Med.  (Obst. 
and  Gyn.  Section),  1909,  May  ;  ^Arch.  /.  Gyn.  1901,  Ixii,  2  ;  '''Ann.  de  Gyn.  et  d'Obsi. 
1901,  249  ;    ^Monats.  f.  Geb.  u.  Gyn.  1903,  xvii,  345  ;    ^Lancet,  1912,  Jan.  13. 

Bryden  Glendining. 

VARICELLA. — {See  Chicken-pox.) 

VARICOCELE. — This  anatomical  defect  is  extremely  common  in  young  men, 
and  the  great  majority  of  them  never  suffer  any  inconvenience  from  it.  In  a 
small  proportion,  however,  it  causes  aching  pain  which  may  be  quite  severe. 
Many  patients  are  very  apprehensive  that  it  will  lead  to  sexual  disability  or  other 
ill  effects,  and  it  appears  to  be  true  that  the  testis  on  that  side  may  be  smaller 
and  softer  than  the  other,  but  it  is  practically  unknown  for  any  interference  with 
function  to  result.  Except  in  rare  cases  of  malignant  growth  of  the  left  kidney 
region  leading  to  the  development  of  a  varicocele,  which  is,  of  course,  of  ill-omen 
under  such  circumstances,  it  is  very  unusual  to  meet  with  men  over  thirty-five 
getting  any  trouble  from  the  venous  dilatation,  and  in  old  men  the  condition  is 
practically  never  seen,  so  that  we  may  take  it  that  varicocele  retrogresses  after 
the  prime  of  life  has  been  passed. 

It  has  been  customary  to  reject  candidates  for  the  services,  if  they  suffer  from 
varicocele,  from  fear  of  future  disability  owing  to  real  or  pretended  pain  ;  but  if  it 
has  given  no  trouble  before  twenty-five,  it  is  not  likely  to  do  so  afterwards. 

The  operation  of  ligature  and  removal  of  the  veins  for  this  ailment  is,  of  course, 
as  trifling  as  any  in  surgery,  as  far  as  the  immediate  mortality  is  concerned ;  it 
must  be  far  below  i  per  cent.  But  it  is  by  no  means  so  certain  that  real  benefit 
will  be  obtained.  Corner  and  Nitch^  examined,  at  considerable  periods  after 
the  operation,  a  hundred  cases  of  varicocele.  They  found  that  in  nearly  one- 
fifth  there  was  still  some  pain,  and  that  4  per  cent  of  the  patients  were  actually 
worse  after  this  treatment,  in  that  they  now  had  symptoms  where  previously 
there  had  been  none.     The  following  table  sums  up  the  results : — 

A  Hundred  Cases  of  Varicocele  examined  subsequently. 


Testis  harder     - 

-     90 

Tense  hydrocele 

8 

Varicocele  recurred 

2 

,,       enlarged  - 

-     55 

Flaccid  hydrocele 

15 

Cured  or  improved 

70 

,,       smaller    - 

-     21 

Spermatocele    - 

2 

♦Neither  better  nor 

Scrotum  thick  - 

-     50 

Pain  in  testis  - 

■     14 

worse  - 

26 

Pain  in  scar     - 

■       5 

*Worse    - 

4 

*  Operated  on  to  enter  the  services ;    Iree  from  symptoms  before  operation. 

Even  the  above  table  does  not  quite  complete  the  list  of  unfortunate  con- 
sequences. The  writer  has  seen  or  conversed  with  two  patients,  operated  on  by 
various  surgeons,  in  which  so  many  vessels  were  taken  away  that  the  testis 
became  gangrenous  and  had  to  be  removed.     Suppuration  occasionally  occurs. 

We  conclude,  therefore,  that  operation  should  only  be  recommended  for 
varicocele  when  it  is  genuinely  a  nuisance  to  the  patient  by  causing  pain  which 
a  suspensory  bandage  is  not  sufficient  to  relieve,  and  that,  in  operating,  care 
should  be  taken  to  leave  the  testis  an  adequate  blood-supply. 

Reference. —  ^Corner  and  Nitch,  Brit.  Med.  Jour.  1906,  i.  ^_  Rendle  Short. 


VARICOSE    VEINS  539 


VARICOSE  VEINS. — It  is  almost  too  well  known  to  require  comment,  that  in 
addition  to  the  aching  pain  so  often  complained  of,  varicose  veins  may  also  lead 
to  ulceration,  eczema,  rupture,  or  thrombosis.  In  rare  cases,  a  fatal  result  may 
follow  from  haemorrhage,  or  pulmonary  embolism  after  thrombosis.  There  is  no 
tendency  to  natural  cure,  except  that  the  varicose  veins  of  pregnancy  improve 
very  much  after  delivery. 

There  are  three  well-recognized  methods  of  operation  for  this  condition  : — 
(i).  Removal  and  ligature  vein  by  vein.  (2).  Trendelenburg's  operation,  division 
and  ligature  of  the  saphena  vein  in  the  groin.  (3).  Schede's  operation,  a  cir- 
cumferential cut  being  made  wholly  or  partly  round  the  leg  just  below  the 
knee,  and  all  the  veins  divided  and  tied. 

1.  Removal  and  Ligature  Vein  by  Vein. — The  objection  to  the  first  method  is 
that  it  is  a  long  and  tedious  operation  if  the  veins  are  numerous.  The  result,  for 
the  years  immediately  following,  depends  entirely  upon  the  thoroughness  of  the 
surgeon.  Many  of  the  cases  get  into  trouble  again,  after  seven  to  ten  years,  from 
the  development  of  a  further  crop  of  veins,  and  this  in  spite  of  conabining  the 
removal  with  a  Trendelenburg  ligature.  It  is  not  common,  however,  for  the 
patient  to  need  a  second  operation.  Jaennel,  in  his  report  to  the  French  Con- 
gress of  Surgery  in  1910,  found  complete  cure  in  patients  followed  frona  a  few 
months  to  ten  years  in  52  out  of  70  cases,  that  is,  74  per  cent.  When  the  whole 
saphena  vein  in  thigh  and  leg  was  removed,  73  out  of  77  (95  per  cent)  were  cured. 

2.  Trendelenburg's  Operation. — It  is  possible  to  obtain  more  definite  evidence 
of  the  effects  of  this  operation — -and  of  Schede's — proceeding,  as  they  do,  upon 
a  more  stereotyped  plan.  Goerlich^  has  made  a  personal  stud}'  of  69  cases 
operated  on  by  the  Trendelenburg  method  in  von  Bruns'  clinic  ;  of  these,  84 
per  cent  were  cured  as  far  as  symptoms  were  concerned,  but  only  27  per  cent 
were  free  from  varices.  In  47  cases  the  saphena  vein  had  been  restored,  in  spite 
of  division  and  ligature.  He  also  collected  the  results  of  1425  literature  cases, 
with  cures  in  from  56  to  85  per  cent.  Miller^  followed,  for  periods  of  from 
six  months  to  ten  years,  41  cases  operated  on  by  the  same  method  in  Hal- 
sted's  clinic.  The  patients  were  pretty  equally  distributed  over  the  various 
years.  Of  19  cases  followed  i  to  4  years,  89  per  cent  were  cured  ;  of  19  cases 
followed  5  to  8  years,  63  per  cent  were  cured.  This  shows  the  danger  of  late 
return  of  the  trouble.  Jaennel  reported  only  56  per  cent  cured  out  of  697  cases 
treated  by  the  Trendelenburg  operation,  and  followed  from  two  months  to  twelve 
years.  When  this  was  combined  with  removal  of  the  prominent  varices,  60  per 
cent  out  of  95  patients,  followed  up  to  fourteen  years,  were  cured.  It  is  prob- 
able, however,  that  the  worst  type  of  cases  were  treated  by  this  method. 

3.  Scliede's  Operation. — The  results  of  this  operation  were  much  less  satisfac- 
tory, though  the  evidence  was  slender.  Only  3  out  of  9  patients  were  cured,  and 
two  of  these  were  quite  recent.  (Edema  of  the  leg  followed  several  times.  It 
was  interesting  to  find  that  the  veins,  in  spite  of  division  and  ligature,  reunited  ; 
photographs  show  them  running  right  across  the  incisional  scar,  and  a  vein 
dissected  out  still  displayed  the  mark  of  the  ligature  upon  it. 

The  principal  danger  of  surgical  treatment  is  pulmonary  embolism,  of  which 
a  fair  number  of  cases  have  been  reported  ;  but  long  series,  comprising  several 
hundreds  of  operations,  have  been  recorded  in  which  this  cause  of  death  does  not 
figure  ;   it  must  be  quite  rare. 

We  conclude,  then,  that  the  best  results  are  given  by  total  removal  of  the 
saphena  vein  in  the  thigh  and  leg  ;  that  multiple  resection  vein  by  vein,  with 
Trendelenburg  ligature,  takes  second  place  ;  that  the  Trendelenburg  ligature 
alone  comes  next  ;    and  that  Schede's  operation  is  not  satisfactory. 

References. —  ^Goerlich,  Beiir.  z.  klin.  Chir.  xliv,  278  ;  -Miller,  Johns  Hop.  Hasp. 
Bull.  1906,  xvii,  289.  ^.  j^^^aig  Short. 


540  INDEX     OF     PROGNOSIS 

VARIOLA. — [See  Small-pox.) 

VOMITING  OF  PREGNANCY.— If  all  cases  in  which  the  vomiting  of 
pregnancy  is  excessive  and  persistent  be  grouped  together,  the  outlook  becomes 
very  favourable.  The  vast  majority  react  perfectly  well  to  efficient  treatment. 
Medical  literature  abounds  in  records  of  two  or  three  cases  successfully  treated 
by  some  special  medicament  when  all  other  means  were  apparently  failing. 
At  the  present  time  these  records  relate  to  cases  treated  with  injections  of 
blood  serum.  Previously,  much  success  attended  thyroid  or  suprarenal  extract 
administration.  The  truth  is,  as  noted  above,  that  the  vast  majority  are  readily 
amenable  to  treatment,  but  there  is  a  small  group — the  toxaemic — which  it  is 
difficult  to  recognize,  and  which  when  inefficiently  treated  suddenly  prove  fatal. 

Whitridge  Williams  classifies  cases  into  the  following  groups  :  (i)  The 
neurotic — by  far  the  most  frequent  ;  (2)  The  toxcsmic — the  most  serious 
group  ;  and  (3)  The  reflex — the  least  frequent.  Underlying  each  of  these  is 
probably  a  chronic  toxaemia — indicative  of  a  failure  of  physiological  adjustment 
between  the  maternal  organism  and  the  foetal  sac  ;  but  the  recognition  of  the 
class  to  which  any  case  belongs  is  never  at  once  self-evident,  but  only  becomes 
revealed  during  the  course  of  treatment. 

Both  the  neurotic  and  the  reflex  groups  react  readily  to  treatnient — such  as 
intestinal  antiseptics,  stomach  washings,  and  a  carefully  restricted  diet,  with 
complete  rest  in  bed.  Thus  J.  H.  Martin  treated  17  cases  in  the  Glasgow 
Maternity  Hospital  by  rest  in  bed,  washing  out  the  stomach,  a  diet  of  peptonized 
milk  or  milk  and  soda,  and  purgation,  with  the  result  that  16  cases  were  cured. 

The  toxaemia  group  is  more  serious.  The  chief  problem  in  these  cases  lies 
in  deciding  when  to  interfere  with  the  pregnancy.  On  the  one  hand,  the  natural 
desire  is  to  allow  the  pregnancy  to  continue  ;  on  the  other,  emptying  the  uterus 
shows  decidedly  good  results,  provided  it  be  not  too  long  delayed.  That  the 
results  are  not  better  is  largely  due  to  the  tendency  on  the  part  of  the  obstetrician 
to  try  how  long  he  can  postpone  evacuation  of  the  uterus,  often  with  disastrous 
results  to  the  patient.  Milder  cases  do  undoubtedly  react  to  absolute  rest 
and  rectal  feeding,  with  saline  subcutaneously. 

The  clinical  features  which  should  be  relied  upon  as  indicating  the  prognosis 
or  calling  for  more  drastic  treatment  are  the  following : — 

1.  The  loss  of  weight  should  not  be  allowed  to  exceed  one-third  of  the  total 
body-weight  ;  this  is  however,  of  little  use  when,  as  often  happens,  the  initial 
weight  is  unknown. 

2.  The  urinary  examination,  though  not  always  reliable,  when  performed 
regularly  and  showing  an  increasingly  high  ammonia  coefficient,  with  a 
diminished  quantity  of  urine  in  the  twentj'-four  hours,  points  to  an  aggravated 
condition.  If  saline  injections  are  being  employed,  this  will  tend  to  keep  up 
the  quantity  of  urine  passed. 

3.  The  pulse  probably  forms  one  of  the  best  guides.  Many  authors  advise 
emptying  the  uterus  when  the  pulse-rate  exceeds  100  per  minute  in  cases  which 
are  being  treated  by  absolute  rest  and  low  diet.  Certain  observers,  however, 
insist  that  a  pulse  of  even  120  is  not  by  itself  of  grave  import. 

4.  The  vomiting,  when  persistent,  and  accompanied  by  wasting  and  a  rise 
in  temperature,  is  to  be  taken  into  account.  Many  cases  cease  vomiting  tow  ard 
the  end,  and  what  is  often  looked  upon  as  an  improvement  is  in  reality  an 
indication  of  approaching  death. 

5.  Delirium  and  diarrhoea  are  indications  of  great  danger. 

In  toxjemic  cases  which  do  not  react  to  ordinary  measures,  recourse  must  be 
had  either  to  thyroid  extract,  suprarenal  extract,  or  blood  serum.     But  little 


VULVA,     CARCINOMA     OF  541 

time  should  be  lost  on  these  measures.  If  within  36  to  48  hours  there  is  no 
improvement,  emptying  of  the  uterus  is  indicated  without  delay.  These 
patients  are  by  this  time  in  too  feeble  a  condition  to  stand  a  large  or  prolonged 
operation  ;  consequently,  from  the  point  of  view  of  prognosis,  it  is  most 
important  that  the  quickest  and  least  brutal  method  should  be  employed.  At 
such  a  stage  of  pregnancy  this  is  undoubtedly  a  vaginal  hysterectomy,  by  which 
the  uterine  contents  can  be  rapidly  removed.  Equally  important,  too,  is  the 
anaesthesia  employed.  The  condition  of  acidosis,  resulting  from  the  starvation 
of  vomiting,  precludes  absolutely  the  use  of  chloroform.  The  best  anaesthetic 
in  such  cases  is  a  combination  of  gas  and  oxygen,  but  ether  may  be  used  where 
the  former  is  for  any  reason  not  available.  It  too  frequently  happens  that  the 
emptying  of  the  uterus  has  been  successfully  accomplished,  but  the  patient 
dies  from  shock  or  from  delayed  chloroform  poisoning. 

Vomiting  of  pregnancy  is  not  an  uncommon  affection.  Robert  Barnes  him- 
self saw  9  patients  succumb  to  it.  The  mortality  of  the  toxaemic  variety  is 
variously  given  as  60  per  cent  by  some  authors  and  30  per  cent  by  others. 

Bryden  Glendining. 

VULVA,  CARCINOMA  OF. — The  growth  in  the  majority  of  cases  is  an 
epithelioma,  and  conforms  to  the  character  of  such  tumours  in  being  com- 
paratively slow- growing.  Its  superficial  position  ought  also  to  lead  to  its  early 
detection;  but  unfortunately,  the  fact  that  the  majority  of  malignant  vulval 
growths  are  secondary  to  leucoplakia  vulvae  has  resulted  in  obscuring  the  onset 
of  malignancy.  In  order  to  rectify  this  tendency,  some  surgeons  insist  that 
it  is  wise  to  regard  leucoplakia  vulvae  as  in  all  respects  comparable  to  leuco- 
plakia of  the  tongue — that  is,  as  a  pre-cancerous  state. 

A  distinction  should  be  made  between  this  group,  arising  in  leucoplakic 
conditions  and  mainly  involving  the  labia,  and  that  group  arising  in  an  other- 
wise healthy  vulva,  and  usually  situated  in  the  neighbourhood  of  the  clitoris 
and  urethra,  for  the  former  is  more  amenable  to  treatment. 

The  factors  mainly  influencing  prognosis,  and  requiring  more  special  con- 
sideration are,  (i)  The' site  oj  growth;  (2)  The  stage  of  advancement  when  first 
seen  ;    and  (3)   The  treatment  adopted. 

1.  The  Site  of  the  Growth. — The  growths  of  the  vulva  are  readily  divided 
into  two  groups.  In  the  first  place  there  is  the  smaller  group  arising  in  the 
vicinity  of  the  clitoris,  in  a  frenal  fold,  where  it  forms  a  small  nodular  mass 
covered  with  unaltered  skin.  The  proximity  of  the  growth,  on  the  one  hand 
to  tne  bone,  which  limits  the  extent  of  resection,  and  on  the  other  hand  to 
the  urethra,  which  is  often  preserved  with  undue  risk  of  recurrence,  both 
affect  the  prognosis  adversely.  Further,  the  rich  lymphatic  drain  of  this 
region   promotes    deposits  in  the  inguinal  glands  of  both  sides. 

The  second  and  larger  group  comprises  those  arising  in  the  labia  ;  here  the 
margin  of  tissue  is  a  little  greater.  These  cases  generally  develop  in  a  pre- 
existing leucoplakia,  and  if  all  cases  of  leucoplakia  vulvae  were  regarded  with 
the  same  suspicion  as  leucoplakia  of  the  tongue,  the  chances  of  early  detection 
and  successful  treatment  of  the  developing  epithelioma  would  be  considerably 
enhanced.  The  growths  in  this  region  more  frequently  ulcerate,  or  show  a 
roughly  papillary  surface,  which  renders  their  nature  unmistakeable  owing  to 
the  clinical  features. 

2.  The  Stage  of  Advancement. — It  is  obvious  that  with  a  growth  already 
down  to  the  underlying  bone,  the  chances  of  recovery  are  small.  In  judging 
of  the  gravity  of  the  case,  the  state  of  the  inguinal  glands  should  be  considered. 
Enlargement  of  the  inguinal  group,  especially  if  slight,  is  by  no  means  an 
indication  of  secondary  deposits,  but  is  to  be  regarded  as  an  index  of  septic 


5  42  INDEX     OF     PROGNOSIS 

absorption  until  the  presence  of  new  growth  has  been  demonstrated  micro- 
scopically. Considerable  enlargement,  however,  does  as  a  rule  indicate  malig- 
nant deposit  ;  but  even  in  these  cases,  radical  operation  offers  the  best  chance 
of   a  cure. 

3.  The  Treatment  Adopted. — Operative  procedure  in  which  a  wide  area 
surrounding  the  growth,  and  also  the  whole  tract  of  lymphatic  drainage,  in- 
cluding the  inguinal  group  of  glands,  are  removed,  will  show  better  results 
than  purely  circumscribed  operations.  Many  operators,  while  widely  resect- 
ing the  region  of  growth,  and  also  removing  the  inguinal  lymph  glands, 
yet  leave  the  connecting  lymphatic  tracts,  with  disastrous  results  as  to 
recurrence. 

Again,  if  leucoplakia  is  regarded  with  due  suspicion,  and  the  earliest  develop- 
ment of  malignant  disease  is  countered  by  wide  resection,  results  will  be  obtained 
showing  great  improvement  on  those  of  the  present  day. 

"When  the  growth  has  recurred,  the  application  of  x  rays,  radium,  and  dia- 
thermic cauterization,  offer  chances  of  considerable  relief  from  the  distress  of  a 
fungating  ulcerated  mass,  and  in  rare  instances  may  even  result  in  a  cure.  The 
application  of  x  rays  and  radium  is  still  of  too  recent  a  date  to  permit  of  the 
compilation  of  figures  of  results,  but  there  is  at  present  no  question  of  the 
relief  afforded  in  otherwise  intractable  conditions.  Bryden  Glendining. 

WHOOPING-COUGH. — The  prognosis  of  this  disease  will  be  considered  under 
the  following  heads  :  (i)  Age  ;  (2)  Sex  ;  (3)  Complications  ;  (4)  Special  sym- 
ptoms ;    (5)  Physical  and  social  conditions  ;    (6)   Season. 

■[_  Age. — The  Aberdeen  figures  furnish  us  with  the  most  trustworthy  infor- 
mation on  this  point.  Whooping-cough  was  made  a  notifiable  disease  in  that 
city  for  the  twenty  years  1882  to  1900,  and  details  have  been  published  which 
o-ives  the  age  incidence  of  the  cases  and  deaths  for  the  last  ten  years  of  that 
period.  During  those  ten  years  there  were  15,093  cases  with  722  deaths,  a 
mortality  of  4-7  per  cent.  The  following  table  shows  the  fatality  at  the 
various  ages  up  to  five  years : — 

Fatality  according  to  Age  (Aberdeen). 


Age 

Fatality 

per  cent 

Under    1 

12-5 

1-2 

10-1 

2-3 

3-3 

3-4 

2-2 

4-5 

1-6 

Over   5 

Under    1 

„      7 

Practically  nil. 

From  these  figures  it  follows  that  whooping-cough  is  a  disease  of  considerable 
danger  to  infants  and  children  under  two  years  ;  but  after  that  age  it  becomes 
niuch  less  serious. 

Cases  treated  in  hospital  show  a  much  higher  fatahty,  because  it  is  the  most 
serious  ones  which  are  sent  to  hospital  for  treatment.  But  the  same  relative 
severity  of  the  disease  according  to  age  still  appears  in  hospital-treated  cases, 
as  is  shown  by  the  foUowing  table,  which  gives  the  numbers  of  cases  and  deaths 
in  the  Metropolitan  Asylums  Board  hospitals  for  the  years  1911  and  1912  : — 


WHOOPING-CO  UGH 


543 


Fatality  according  to  Age  (Metropolitan  Asylums  Board). 


Age 

Cases 

Deaths 

Fatality 
per  cent 

Under    1 

380 

89 

23-4 

1-  2 

777 

116 

14-9 

2-  3 

601 

45 

7-4 

3-  4 

444 

24 

5-4 

4-  5 

332 

8 

2-4 

Under    5 

2534 

282 

11-1 

5-10 

363 

8 

2-2 

10-15 

17 

0 

0  0 

15  &  over 

1 

0 

0-0 

Total     - 

2915 

290 

9-9 

2.  Sex. — The  Aberdeen  figures  show  that  the  fatahty  in  this  respect,  for  all 
ages,  was  the  same,  4-7  per  cent  ;  and  that  amongst  the  patients  over  six  years 
of  age  there  were  no  deaths  amongst  the  males,  though  there  were  several  amongst 
the  females. 

3.  Complications. — In  whooping-cough  death  is  mi:ch  more  often  due  to  some 
complication  than  to  the  virulence  of  the  disease  itself.  Of  these  complications 
the  most  formidable  is  bronchopneumonia.  It  occurs  in  10  to  15  per  cent  of  cases 
treated  in  hospital,  and  from  25  to  50  per  cent  of  those  so  afiected  die. 

Convulsions  are  also  extremely  serious.  According  to  the  returns  of  the 
Metropolitan  Asylums  Board,  they  are  met  with  in  2  per  cent  of  the  cases. 
Convulsions  are  most  grave  when  they  occur  apart  from  lung  complications,  and 
when  they  are  repeated. 

Otitis  media  arises  in  about  5  per  cent  of  the  cases. 

Cerebral  complications  are  fortunately  uncommon.  They  are  highly  dangerous  ; 
and  if  not  immediately  fatal,  they  often  lead  to  permanent  impairment  of  the 
functions  of  some  part  of  the  nervous  system. 

4.  Special  Conditions. — As  a  rule  the  longer  the  duration  of  the  catarrhal, 
the  less  severe  is  the  paroxysmal  stage.  The  severity  of  the  latter  chiefly 
depends  upon  the  frequency  and  intensity  of  the  paroxysms.  The  ability  of  the 
child  to  retain  his  food  has  a  great  influence.  Frequent  vomiting,  which  often 
goes  with  frequency  of  paroxysm,  retards  recovery,  and  may  contribute  to  a  fatal 
result. 

5.  Physical  and  Social  Conditions. — Ill-fed,  rickety,  and  tuberculous  children 
are  very  bad  subjects.  Even  in  a  normal  child  a  severe  attack  of  whooping- 
cough,  especially  if  complicated  with  bronchopneumonia,  may  result  in  per- 
manent thoracic  deformity  or  chronic  pulmonary  disease  ;  but  such  results  are 
most  hkely  to  follow  in  the  case  ot  rickety  patients. 

Adenoids  and  enlarged  tonsils  will  often  prolong  the  paroxysmal  stage. 

In  the  Aberdeen  cases  it  was  found  that  while  the  average  fatality  was  4-7 
per  cent,  that  of  patients  in  families  living  in  one  room  was  7-8  per  cent  ;  in 
those  Uving  in  two  rooms,  5  per  cent  ;  in  three  rooms,  4-5  per  cent ;  in  four 
rooms,  34  per  cent  ;  and  in  fiv  ■  rooms  or  more,  22  per  cent.  This  may  be  taken 
as  evidence  that  the  social  state  of  the  patient  considerably  affects  his  chances  of 
recovery. 

6.  Season. — In  Aberdeen  it  was  found  that  the  fatality  was  highest  in  the 


544 


INDEX     OF     PROGNOSIS 


months  of  February,  April,  and  May — the  end  of  winter  and  the  beginning  of 
the  spring  (6-5  to  6-9  per  cent).  As  in  this  disease  death  usually  takes  place 
somewhat  late  in  its  course,  the  onset  of  these  fatal  cases  may  be  referred  to  the 
winter  or  the  end  of  the  autumn.  On  the  other  hand,  the  fatahty  was  lowest 
in  October  and  November  (3-8  per  cent)  ;  here  the  onset  of  the  disease  was 
during  the  autumn  or  in  the  late  summer. 

Whooping-cough,  like  most  of  the  acute  infectious  diseases,  varies  considerably 
in  its  virulence  from  time  to  time.  Thus  in  Aberdeen  the  average  fatality  for 
the  years  1882  to  1889  was  10-5  per  cent ;  while  for  the  years  1900  to  1910  it  was 
5-3  per  cent.  £.  w.  Goodall. 

YELLOW  FEVER. — This  is  one  of  the  diseases  that  varies  with  different 
epidemics.  It  is  more  severe  when  it  attacks  a  population  that  has  not 
previously  suffered  from  it.  Race  per  se  does  not  protect,  but  in  the  coloured 
races  the  mortality  is  rarely  so  high  as  in  the  European.  During  the  earliest 
West  Indian  epidemics  it  was  noted  as  attacking  persons  of  all  races,  and  in 
groups  of  negroes  a  high  mortality  was  noted.  Clarke,  in  Dominica,  writing  of 
the  epidemic  there  in  1793,  mentions  a  gang  of  24  newly-imported  negroes  from 
West  Africa,  of  whom  one-third  died  ;  and  the  general  mortality  in  persons 
attacked  throughout  the  West  Indies  at  that  time  was  from  one-third  to  two- 
thirds  of  the  whole.  Blair,  in  Demerara,  in  the  epidemic  of  1843,  gives  the  case- 
mortality  as  13-3  per  cent,  and  in  that  he  includes  the  mild  type  then  clearly 
recognized,  nearly  1000  cases  of  which  he  dealt  with  without  any  deaths.  In 
the  1853  epidemic,  dealing  mainly  with  new  arrivals — i.e.,  non-immunes — he 
gives  the  following  table  : — 

Mortality  of  Yellow  Fever,  Demerara  Epidemic,  1853.    (Blair.) 


Race 

Cases 

Deaths 

Case- 
mortality 

Seamen 

Indians 

Portuguese   (Madeira) 

Creoles 

1242 

42 

698 

17 

328 

U 

246 

2 

per  cent 

27 
26 
35 
11 

Total 

1999 

.587 

29-35 

In  the  Bermuda  outbreaks,  the  case-mortality  varies  greatly  in  the  differen 
races :     in   the    last   big   epidemic    there    were    only    3     deaths    in  1469  cases 
amongst  negroes,  or  0-2  per   cent,  whilst  49  per  1000  of   the  white    population 
died. 

At  the  present  time,  interest  in  the  mild  form  of  the  disease  first  described  in 
1841  is  great,  as  these  mild  cases  are  by  some  believed  to  form  the  reservoir 
of  the  disease,  and  to  be  more  widely  and  persistently  prevalent  than  had  been 
previously  thought. 

Amongst  the  well-marked  cases  in  West  Africa  the  mortality  is  high.  Home 
and  Meyers  report  64  cases  with  51  deaths,  or  79  per  cent.  Of  the  13  who 
recovered,  4  were  negroes.  The  mortality  in  negro  patients  was  35  per  cent. 
Whether  the  excessive  mortality  in  West  Africa  is  due  to  the  non-recognition 
of  the  milder  cases,  or  to  the  spread  of  a  disease  in  a  population  now  non- 
immune, may  be  doubtful.  C.  W.  Daniels. 


545 


SUPPLEMENTARY     INDEX 


A  BDOMEN,  contusions  of           . .  i 
■^     —  perforating     and      gunshot 

wounds  of           .  .           .  .  4 

Abdominal  actinomycosis    . .          .  .  8 

—  aneurysm  (see  Aiieurj'sm,  Abdo- 

minal) . .          . .          . .          . .  37 

—  diseases,    gastric    symptoms    as- 

sociated with  . .          . .           .  .  494 

ABDOMINAL  INJURIES            .  .            .  .  I 

—  pain  with  arteriosclerosis          .  .  84 

—  symptoms  of  rheumatic  fever    . .  449 
Abortion,  induction  in  mental  disease 

of  pregnancy              . .          . .  332 

—  malaria  predisposing  to              . .  288 

—  puerperal  sepsis  after      . .          .  .  416 
Abscess,  appendical,  recurrence  of .  .  72 

—  cerebral,  relation  to  aphasia      .  .  53 

—  hydatid,  of  liver  .  .          . .          . .  233 

—  intracranial,  following  ear  disease  244 

—  of  liver,  amoebic. .  . .        140,  156 

—  pancreas    . .          . .           .  .          . .  '385 

—  psoas  (see  Psoas  Abscess)          . .  412 

—  relation  to  previous  appendicitis  70 

—  secondary   to   appendicitis         .  .  57 

—  subphrenic  (see   Subphrenic   Ab- 

scess)    . .          . .          . .          . .  502 

Acapnia,  relation  to  anaesthetics    . .  33 
Accessory  sinusitis  of  the  nose  (see 

Nasal   Accessory   Sinuses) 
Acetonuria  in  diabetes  mellitus 

145,   147,  150 

ACIDOSIS           5 

—  post-anaesthetic    .  .           .  .          . .  30 

—  with  cirrhosis  of  liver      . .          . .  279 

—  mvocardial  disease          . .           . .  353 

ACROiVTEGALY               7 

ACTINOMYCOSIS           8 

Acupuncture  in  abdominal  aneurysm  38 

Acute  yellow  atrophy  of  liver       . .  276 

ADDISON'S  DISEASE                  .  .            .  .  9 

—  —  danger  signals             ..          ..  11 

syphilis  as  cause        . .          . .  9 

Adenocarcinoma  of  ovary    . .           .  .  382 

Adenoma  of  kidney  . .          . .           . .  251 

Adenomatous  goitre              . .           . .  199 

Adhesions,  chronic  pericardial        . .  392 

—  following  sprains              . .          . .  250 
Adirondack     Sanatorium    for    con- 
sumption, statistics  of  treat- 
ment at           . .          . .          .  .  428 

Adolescence,    frequency   of  arrhj'th- 

mia  in              . .           . .           .  .  430 

—  mental  disturbances  of  . .          . .  333 
Adolescent     insanity,      analogy     of 

imbecility   to           .  .          .  .  334 

facial  expression  in   . .          .  .  301 

liability  to  recurrence          .  .  334 

as  prelude  to  dementia       . .  322 


Adrenal    medication    in    Addison's 

disease . . 
Adrenine  in  spinal  and  local  anal- 
gesia    . . 
African  tick  fever 
Age  in  relation  to  anesthetics 
Air  hunger  in  abdominal  contusions 
ALBUMINURIA  

—  association  with  ascites  . . 

—  due    to   circulatory   disturbances 

—  cyclical 

—  febrile  and  non-febrile     .  . 

—  in  hemiplegia 

—  physiological 
of  pregnancy    .  . 

—  in  puerperal  sepsis 

—  scarlet    fever 

Albuminuric  retinitis  of  chronic 
nephritis 

Albumosuria,  myelopathic    . . 

Alcoholism  dating  from  influenza  .  . 

Alkalinity  of  blood,  reduction  afford- 
ing valuable  indications 

Alkaloids  in  diminishing  surgical 
shock    . . 

—  with  general  anesthesia  . . 
Alcohol  in  etiology  of  arteriosclerosis 

—  injection    of    superior    laryngeal 

nerve   in   tuberculosis 

—  —  in  trigeminal  neuralgia 
Alcohol-chloroform-ether  anaesthesia, 

relative  safety  of 
Alcoholic  cirrhosis  of  liver  .  . 

—  neuritis,    muscular    atrophy    due 

to  

—  poisoning,  neuritis  due  to 
Alcoholics,  glycosuria  in 

—  pneumonia  in 

—  tuberculosis  in      .  . 
Alcoholism  (see  JMental  Diseases)     . . 

—  chronic,  myocardial  disease  due 

to  

—  dipsomania 

—  and  epilepsy 

—  syphilis  with 
Alypin  in  local  analgesia 
Amentia  (see  Mental  Diseases) 
Ammonia  excretion,  indications     . . 
Amcebic  dysentery       .  .          . .         139, 
Amputation  of  penis  for  cancer     .  . 
ANiEMIA,  APLASTIC 

—  —  indication  of  secondary   ane- 

mia becoming 

—  and  dangers  of  anesthetics 

—  gravity  of,  in  portal  cirrhosis  . . 

—  of  lactational  insanity     .  . 

—  limits  justifying  surgical  interven- 

tion 

35 


10 
29 

447 
29 


13 


501 
II 

13 
416 
466 

366 
logi 
338 


34 

24 
81 

269 
376 

23 
277 

347 
377 
145 
404 
420 
326 

350 
320 
331 
505 

25 

322 

6 

156 

388 

14 

16 

32 

279 

332 

16 


546 


INDEX     OF     PROGNOSIS 


Anaemia  in  lymphadenoma . . 

—  lymphatic  leukaemia 

—  pernicious  (see  Pernicious  Anae- 

mia) 
AN-SIMIA,  SECONDARY 

ANEMIA,  SPLENIC 

ascites  due  to . . 

of  infancy 

Anaesthesia,  acidosis  due  to 

—  brachial  paralysis  after  . . 

—  influence  of  previous  sod.  bicarb. 

and  glucose  treatment 

—  in  surgery  of  diabetics   . . 

AN.a:STHETICS  

— •  and  acidosis  ■  •  •  •        .  •  • 

—  the    administrator    as    the    im- 

portant factor  .  •  ■  • 

—  anaemia  an  important  factor  in . . 

—  measures    to   prevent    complica- 

tions  . . 

—  methods  of  employment 

—  mixtures  of 

—  in    operation    for    vomitmg    of 

pregnancy 

—  physical    and    mental    state    of 

patient 

—  post -operative  effects 

—  relative  safety  of  various 

—  and  status  lymphaticus  . . 
Anal  prolapse 
Analgesia,  spinal,  after-effects 

contra-indications 

death-rate  under 

methods  of      .  • 

Analgesics 

ANEURYSM,  ABDOMINAL       .  • 

influence  of  treatment 

—  with  aortic  regurgitation 

—  arteriovenous 

—  cardiac  syphilis  with 
ANEURYSM,  INTRATHORACIC 
influence    of    age,    sex, 

occupation  . . 

—  —  —  treatment 
life    expectation    comparison 

with  abdominal 

multiple 

ANEURYSM     OP     PERIPHERAL     AR- 
TERIES   

Aneurysmal  varix 
Aneurysmorrhaphy    .  • 
Angina  ludovici 

ANGINA  PECTORIS 

arteriosclerosis  as  cause 

circumstances   provoking   at- 
tacks 

—  '  pseudo  '  or  toxic 

—  as      symptom      of      myocardial 

disease 
Angioneurotic    oedema,    dangers    of 

anesthesia  in 
Ankle,  fracture  of  bones  of  i8i, 

—  sprained     . . 

—  tuberculosis  of     . .  .  •  •  • 
Anterior    poliomyelitis    (see    Polio- 
myelitis)          - .          •  •        237, 

ANTHRAX 

Antigonococcal  serum  in  menmgitis 


PAGE 

287 

272 


and 


395 
15 
16 

89 

18 
5,  7 
375 

7 

149 

19 

30 

19 
32 

36 
27 
23 

541 

29 
35 
22 
29 

442 
36 
27 
26 
29 
25 
37 
38 

225 
47 

122 
39 

40 
42 

37 

42 

43 
47 
44 
124 
47 
84 

49 
51 

353 

36 
190 
249 


348 

51 

295 


Antitoxin  treatment  and  diphtheritic  ' 

heart  failure  . . 

of  tetanus 

Antityphoid  inoculation 

Antyllus  operation  in  aneurysm     . . 

Anuria,  calculous 

Anus,  artificial,  effect  on  patients . . 

ANUS,  IMPERFORATE 

Aorta,  aneurysm  of  (see  Aneurysm, 

Intrathoracic) 

—  coarctation  of 
AORTA,  DILATATION  OF 

Aortic    iacompetence    with    angina 
pectoris 

—  and     mitral     valvular     disease, 

combined 

—  regurgitation 

effect  of  treatment    . . 

—  stenosis 

APHASLA.  

Aphthous  stomatitis . . 
Aplastic  anaemia 
Apoplectiform  bulbar  palsy. . 
Apoplexy  (see  Strokes)  _ 

—  mental  symptoms  with  . . 
APPENDICITIS  

—  acute 

bacteriology    .  - 

complications 

mortality  table 

when  to  operate        • . 

pregnancy  complicating 

—  —  recurrence 

results  of  operation  . . 

— •  —  sex  and  age  incidence 
suppurative  cholecystitis  simu- 
lating 

—  chronic,    and    conditions    associ- 

ated with  it    . . 

—  following  blow  on  abdomen 

—  gastric  symptoms  with  . . 

—  prognosis  of  future  attacks  and 

complications 

—  subphrenic  abscess  complicating 
Appendix,  actinomycosis  of 

—  dyspepsia  . . 

—  important  part  played  in  diseases 

of  upper  abdomen    . . 
Arrhythmia  (see  Pulse,  Irregularities 
of)         ^.-z 

—  in  acute  rheumatic  myocarditis 

—  the  great  importance  of  accurate 

diagnosis 

—  with  mitral  stenosis 

—  in  myocardial  disease     . . 

—  total  

Arsenic  in  lymphadenoma  . . 

—  medullary  leukaemia 

—  pernicious  anaemia 
ARSENIC  POISONING 

mental  symptoms  of . . 

—  in  psoriasis  .  •  •  ■  •.  • 
Arterial  degeneration  in  melancholia 

—  disease,  hemiplegia  from 

—  embolism,      mental      symptoms 

due  to 

—  hasmatoma 

—  lesions  in  angina  pectoris 


349 
512 
523 

44 
261 
446 

52 

39 

230 

52 

48 

228 

224 

227 

227 
53 

499 
14 

119 

500 

328 
54 
54 
66 
56 
74 
68 

67 
69 

54 
73 

132 

74 

2 

494 

76 

502 

8 

74 

76 

430 
452 

431 

222 

357 

432 
286 
273 

398 

77 
340 
414 
308 
500 

328 

206 

48 


SUPPLEMENTARY    INDEX 

547 

PAGE 

PAGE 

ARTERIAL  TENSION,  HIGH   .  . 

78 

Auricular  fibrillation 

432 

with   asthma 

93 

—  flutter  (see  Pulse,  Irregularities  of) 

432 

calamity  preceded  by  ap- 

— —  and  fibrillation  in  myocardial 

parently   trifling  sym- 

disease 

357 

ptoms  .  . 

79 

Axillary  aneurysm    . . 

46 

in  chronic  interstitial  ne- 

Azoospermia after  epididymectomy 

167 

phritis  . . 

366 

Azoturia 

144 

effects  of  treatment 

79 

and   myocardial    degener- 

-pACILLARY dysentery   . .         138, 
-L>     Bacillus    aerogenes   capsulatus, 

155 

ation     . . 

351 

Arteries,  peripheral,  aneurysm  of    .  . 

43 

gangrene  due  to 

379 

ARTERIOSCLEROSIS 

80 

—  coli  pyelocystitis 

437 

—  dangers  of  anesthetics  in 

33 

—  oedematis  maligni,  gangrene  due 

—  distribution  of  changes  in 

85 

to           

379 

—  etiological  factors 

80 

—  paralyticans     in     causation     of 

—  with  mental  disturbances  of  old 

general  paralysis        . .      '     .  . 

324 

age 

336 

—  paratyphosus  A  and  B    . . 

386 

—  pneumonia  with  . . 

404 

Bacteriology    of    acute    appendicitis 

66 

—  relation  to  aphasia 

53 

—  empyema  . . 

163 

—  stage  of  development 

83 

—  pleuritis 

401 

—  and  valvular  disease 

218 

—  puerperal  sepsis  . . 

416 

Arteriovenous  aneurysm 

47 

—  ulcerative  endocarditis  . . 

164 

Arthritic  muscular  atrophy    . . 

347 

Bands,      intestinal,      and      chronic 

Arthritis,  acute,  of  infants  . . 

380 

appendicitis     . . 

76 

—  following  sprains.. 

250 

complicating  appendicitis     . . 

61 

—  gummatous 

506 

obstruction  due  to     .  . 

241 

—  gonorrhceal            .  .           . .         201, 

204 

Banti's  disease  (see  Anaemia,  Splenic) 

16 

—  rheumatic  (see  Rheumatic  Fever) 

447 

ascites  due  to. . 

89 

ARTHRITIS,  TUBERCULOUS  .  . 

85 

Bardenheuer's   method  in   fractures 

174 

Arthropathies,  tabetic 

508 

Bassini  method  in  inguinal  hernia  .  . 

214 

ASCITES             

88 

Bath  treatment  of  typhoid  fever    . . 

521 

—  in  biliary  cirrhosis 

280 

Bedsores  in  hemiplegia 

502 

—  complicating  ovarian  tumours  . . 

382 

Bence- Jones's  proteinuria    .  . 

13 

—  operative  treatment 

90 

Bennett's  fracture     . . 

186 

—  in  portal  cirrhosis 

278 

BERI-BERI                       

95 

paracentesis    and   surgical 

Beta-oxybutyric    acid    in    test    for 

treatment 

278 

acidosis 

5 

—  prognosis  from  cytological  data 

92 

Bile-ducts,  cancer  of,  after  gall-stones 

194 

—  and  the  question  of  splenectomy 

18 

Bilharziosis     complicating     vesical 

Ascitic  fluid,  physical  characters  of 

91 

calculus 

96 

Asphyxia  in  papilloma  of  larynx    .  . 

267 

Biliary  cirrhosis  of  liver 

280 

Aspiration  of  hydatid  cyst  . . 

233 

—  complications  of  apj)^endicitis    . . 

62 

Aspirin  in  rheumatic  fever  .  . 

449 

Birth  paralysis  of  brachial  plexus  .  . 

374 

ASTHMA,  BRONCHIAL 

92 

Bismuth   paste   injections   in   nasal 

—  '  cardiac,'  with  angina  pectoris. . 

49 

accessory  sinusitis     . . 

360 

from      impaired      ventricular 

BLACKWATER  FEVER 

95 

contractibility 

353 

Bladder,    atony    of,    prostatectomy 

Astragalus,  fracture  of 

181 

and 

410 

Asylums  (see  Mental  Hospitals)     298 

302 

BLADDER,  CALCULUS  OF 

95 

Ataxia,    mistaken   diagnosis   in   dis- 

 recurrence  after  operation  . . 

98 

seminated  sclerosis    . . 

153 

results  of  operation  .  . 

97 

—  plumbic 

271 

vesical  and  renal  complications 

96 

ATAXIAS  (see  also  Tabes  Dorsalis,  506) 

93 

—  complications  in  pyonephrosis  . . 

441 

Atheroma    with    malaria,     cerebral 

BLADDER,  EXSTROPHY  OF   . . 

98 

haemorrhage  due  to  .  . 

288 

—  —  results  of  various  operations 

99 

—  mental  disturbances  of  old  age  .  . 

336 

BLADDER,  GROWTHS  OF 

100 

—  mistaken  for  abdominal  aneurysm 

37 

—  gunshot  wounds  of 

5 

Athletics,   influence  on   albuminuria 

12 

—  malignant  growths 

102 

Atrophies,    muscular    (see   Muscular 

results  of  operation 

104 

Atrophies) 

347 

suitability  for  operation. . 

103 

Atrophy  of  liver,  acute  yellow 

276 

—  papilloma  of 

100 

Atropine  with  general  anaesthesia  .  . 

24 

pre-cancerous  nature  of 

103 

—  influence  on  post-operative  vomit- 

— rupture  of 

3 

ing        

35 

—  total  extirpation  of,  results 

105 

surgical   shock 

34 

—  troubles  in  tabes  dorsalis 

507 

Aura  in  epilepsy 

169 

BLADDER,  TUBERCULOSIS  OF 

105 

Auricles,    conditions    of,    in    mitral 

relation  to  epididymitis 

166 

stenosis 

222 

Blindness  from  measles 

290 

548 


INDEX     OF     PROGNOSIS 


PAGE 
294 


395 


207 
14 


Blindness  from  meningitis     . . 

—  in  tabes  dorsalis  .  . 
Blood  alkalinitjr  reduction,  valuable 

indications 

—  changes  in  pernicious  anaemia  . . 

—  coagulation,   iafluence  in  haemo- 

philia   .  . 

—  count  in  aplastic  ansmia 

—  —  leukaemia 
secondary  anaemia 

—  —  splenic  anaemia 
—  —  of  iafancy 

—  dissemination    of  melanotic   sar- 

coma   . . 

—  examination  in  puerperal  sepsis 

—  pressure    in    chronic    interstitial 

nephritis 
hemiplegia 

—  —  high  (see  Arterial  Tension)   .  . 

—  —  — and  myocardial  degeneration  352 

—  —  —  pre-eclamptic        . .  . .        13 

—  —  relation  of  anaesthetics  to     . .        33 

—  serum  in   excessive   vomiting  of 

pregnancy        .  .  .  .         540,   541 

—  transfusion  in  pernicious  anaemia     399 
Blood-stained  ascites 
Boils  with  diabetes    . . 
Bone  affections  in  tabes 

—  changes  of  congenital  talipes     .  . 

—  excision  in  Volkmann's  parah'sis 
Bone-marrow  administration  in  per- 
nicious anaemia 

BONE  TUMOURS  

Bothriocephalus     latus,     pernicious 

anaemia  due  to 
'  Botryoid '    liver    due    to     sj^philitic 

cicatrices 
Bottini's     operation     in     enlarged 

prostate 
Brachial  artery,  hematoma  of 

—  plexus  injuries 
Brain,  actinomycosis  of 

—  changes  in,  in  chron.ic  alcoholism 
relation  to  mental  diseases  .  . 

—  diseases,    orgamic,    mental    sym- 

ptoms of 

—  injuries  of  (see  Head  Injuries)  . . 
functional    defects    following 

—  lesions  due  to  anteriosclerosis 

—  syphilitic  disease  of 

—  tumours  of  (see  Cerebral  Tumoirr) 

124,   125 

—  —  ataxia  due  to 
BREAST,  CANCER  OF 

—  —  apart   from  operation 

—  —  influence  of  pleural  adhesions 
operation      and      recurrence 

after 

—  —  prognosis  after  recurrence    .  . 

simple  diseases  preceding     .  . 

BREAST,  SIMPLE  DISEASES  OF 
Breathlessness  (see  Dyspnoea) 
Bright's  disease  (see  Nephritis) 

with  mental  sj^mptoms 

British    Medical    Association    Com- 
mittee on  Fractures  . . 

Bromide      treatment      of     epileptic 

insanity  . .  . .  . .      330 


272,  273 
15 
17 


291 
416 

366 

501 

78 


92 

148 
508 
509 
347 

398 
106 

395 
2S1 

412 
206 
374 
9 
327 
296 

328 
210 
212 
84,85 
325 


94 
no 
no 
115 

III 
112 
116 
n6 

362 
338 

175 


PAGE 

Bronchial     asthma     (see     Asthma, 

Bronchial)        . .          . .          . .  92 

—  disease,  dangers  of  anaesthetics  in  33 

BRONCHIECTASIS         1 16 

BRONCHITIS 118 

—  with  measles         . .          . .          . .  289 

—  recrudescence     after     inhalation 

anesthesia       . .          . .          . .  35 

BRONCHOPNEUMONIA             .  .            .  .  1 18 

—  complicating  appendicitis          . .  60 

measles             . .          . .          . .  289 

whooping-cough         . .          . .  543 

Bronzed  diabetes       . .          . .          . .  148 

Brophy's  operation  for  cleft  palate  137 
Brouardel's  tables  of  work  capacity 

after  fractures             . .         188,  189 

Bruit  de  galop  in  contractile  failure  355 

Buboes  of  neck  in  tj-phus  fever     . .  524 

BULBAR  PALSY            .  .            .  .            .  .  II9 

muscular  atrophy  due  to      . .  348 

Bullous  diseases  (see  Pemphigus)    . .  386 

BURNS  AND  SCALDS                .  .            .  .  I20 

r^^CUM,  actinomycosis  of  . .  8 
^-^     —  gastric  symptoms  associated 

with  aft'ections  of              .  .  494 

—  tulaerciilous              . .          . .          .  .  121 

Calcaneum,  fracture  of         . .          .  .  181 

Calcined  magnesia  in  papilloma  of 

lar^Tix  .  .          . .          .  .           . .  267 

Calculi    after   prostatectomy            .  .  410 

—  prostatic   (see   Prostatic   Calculi)  412 

—  renal  (see  Kidney,  Calculi  of)     . .  258 

—  —  complicating   vesical  calculus  97 

—  —  with  gastric  s^'mptoms        .  .  495 

—  vesical  (see  Bladder,  Calculus  of)  95 
Calculous  anuria        .  .          . .          .  .  261 

Cancer  of  breast  (see  Breast)          . .  no 

—  colon  (see  Colon) . .          . .          . .  140 

—  following  *'-ray  treatment          .  .  283 

—  intestinal  obstruction  due  to     . .  243 

—  of  jaw        .  .           . .           . .          . .  247 

—  kidney        . .          . .          . .          . .  251 

—  lai-ynx  (see  Lar}.Tix)        . .          . .  265 

—  lip  (see  Lip,  Cancer  of)   . .          . .  274 

—  ovaries       . .          . .          . .          . .  381 

—  penis  (see   Penis,   Carcinoma  of)  387 

—  pericarditis  with              . .          .  .  390 

—  of  prostate  (see  Prostate,  Cancer 

of)         408 

—  pulmonary  tuberculosis  with     . .  420 

—  of  rectum  (see  Rectum,  Cancer  of)  442 

—  relation  of  gastric  ulcer  to        . .  489 

—  of  scrotum            . .          . .          . .  469 

—  as  sequel  to  gall-stones  . .          . .  194 

—  of  spine      . .          . .          . .          .  .  484 

—  stomach     .  .          .  .          . .        486,  496 

—  — -  pernicious  anaemia  due  to  . .  395 

—  testis          . .          . .          . .          . .  510 

— ■  '  th}-roid  '  . .          . .          .  .          .  .  109 

—  of  tongue  (see  Tongue,  Cancer  of)  513 

—  uterus  (see  Uterus,  Cancer  of)   . .  526 

—  —  fibroids  as  predisposing  causes  532 

—  vesicular  mole  as  origin  of        . .  343 

—  vulva  (see  Vulva,  Carcinoma  of)  541 
Cancerous  stricture  of  oesophagus  .  .  379 
Cancrum  oris  .  .            .  .          ■ .          •  •  122 

—  -  complicating  measles           . .  290 


SUPPLEMENTARY    INDEX 


549 


PAGE 

Carbohydrate     deficiency,     acidosis 

due  to. .  . .  . .  . .  5 

Carbolic  acid  and  sling  method  in 

movable  kidney     . .  .  .      345 

in  tetanus       ..  ..        512,  513 

Carbon-dioxide  snow  in  rodent  ulcer     463 

Carbuncle  with  diabetes 

Carcinoma   (see   Cancer) 

'  Cardiac     asthma '     with    angina 

pectoris 

from      impaired      ventricular 

contractility 
CAEDIAC  SYPHILIS 

myocardial  degeneration  in 

Cardiolj'sis  in  chronic  adhesive  peri 

carditis 
Cardiosclerosis  (see  Myocardium,  Pri 

mary  Disease  of) 
Cardiospasm    . . 
Cardiovascular  signs  of  hemiplegia . 

—  system  in  acute  nephritis 
Carditis,  acute,  rheumatic  (see  Rheu 

matic  Pericarditis,  etc.) 
Caries  of  spine  (see  Spinal  Caries) 

abscess  from  . . 

Carotid  aneurysm 

—  arter}^  hfematoma  of 
Carpal  scaphoid,  fracture  of 
Caesarean  section  in  eclampsia 

—  —  placenta  prsevia 
Castration  in  hypertrophy  of  prostat 

—  tuberculous  orchitis 
Catalepsy  in  adolescent  insanity 
Cataract  in  diabetes.  . 
Catarrh  with  asthma 
Catarrhal   stomatitis.. 
Catheterism,  retrograde,  in  stricture 

of  oesophagus 

—  ureteral,     importance     in    renal 

growths            .  .           .  .          .  .  252 

Cauda  equina,  injury  of       . .          .  .  482 

Cauterization  in  cancer  of  uterus  . .  529 
vulva    . .          . .          . .          . .  542 

—  treatment  of  asthma  . .  . .  93 
CELLULITIS                    123 

—  cervical,  with  scarlet  fever  . .  466 
Cerebellar  abscess  following  ear  disease  244 

—  lesions,  ataxia  due  to  . .  .  .  94 
Cerebral   abscess        . .           . .           .  .  244 

—  complications  of  whooping-cough  543 

—  haemorrhage    (see   Strokes)         . .  500 

—  —  with  mitral  stenosis..          ..  223 

—  irritation  after  head  injuries     . .  212 

—  lesions  due  to  arteriosclerosis     84,  85 

causing  aphasia         . .          . .  53 

mental  symptoms  with        . .  328 

—  symptoms  of  lead  poisoning     . .  271 

—  —  with  mumps   .  .          . .          . .  346 

—  —  in  typhus  fever         . .          . .  524 

—  —  ataxia  due  to. .          . .          . .  94 

—  —  disseminated     sclerosis     i 

taken  for     . .  . .  . .  153 

CEREBRAL  TUMOUR,  MEDICAL  .  .  124 

—  —  results  of  operation  .  .  . .  127 
CEREBRAL  TUMOUR,  SURGICAL  .  .  124 
Cerebrospinal    fluid,    escape    of,  in 

head  injuries 

—  meningitis  (see  Meningitis)         . .     294 


148 


49 

353 
122 
351 

392 

349 
379 
501 
363 

450 
477 
412 
47 
206 
186 
158 
399 
409 
167 

334 
149 

93 

499 

379 


Cervical  cellulitis  with  scarlet  fever 

—  dilatation  in  eclampsia  .  . 
CERVICAL  RIB  

—  —  nerve  injury  due  to    . . 

—  spine,  fracture  and  dislocation  of 
Cervicitis,   gonorrhoeal 

Cervix  uteri,  cancer  of 
Charcot's  Joints 

—  —  in  tabes 

Charcot-Marie-Tooth  type  of  muscu- 
lar atrophy 

Cheyne-Stokes    breathing    in    hemi- 
plegia 
- —  —  myocardial  disease    . . 

CHICKEN-POX 

dilldbirtli,     mental     diseases    associ- 
ated with 
Children,  acidosis  in  cyclic  vomiting 

—  bronchitis     and     bronchopneu- 

•  monia  in 

—  delirium  of 

—  development  of  mental  inhibition 

—  frequencv  of  arrhythmia  in 

—  mental  disturbances  of  . . 

—  new  growths  of  kidney  in 

—  pyelitis  of 

—  in  relation  to  anaesthetics 

—  rheumatoid  arthritis  of  .  . 
Chimney-sweep's  cancer 
Chloral  habit  . . 

—  poisoning  .  . 

Chlorbutyl,      influence      on      post- 
operative vomiting    . . 

—  pre-anaesthetic  administraton  of 
Chloroform  anaesthesia,  methods  of 
• —  —  relative  safety   of 

—  contra-indication  in  jaimdice    .  . 

—  poisoning,   delayed 

—  —  —  following   appendicectomy 

—  relation  to  status  lymphaticus  . . 

—  —  surgical  shock 

—  in  spinal  analgesia 
Chloroma 

CHLOROSIS  

Cholecystectomy      and      cholecyst- 

otomy  for  gall-stones 
Cholecystenterostomy     in     chronic 

pancreatitis 
CHOLECYSTITIS  

—  with  chronic  appendicitis 

—  from  gall-stones  . . 
Cholelithiasis  (see  Gall-stones) 
Cholera 

—  infantum 
Chondroma 

—  of  testis 
CHOREA 

—  benefits    and    dangers    of    drug 

treatment 

—  mental  symptoms  in 
CHORION-EPITHELIOMA 

—  following  vesicular  mole 
Chrysarobin    treatment   of   psoriasis 
Circulatory  disturbances,  albuminuria 

due  to  . . 

—  lesions,  dangers  of  anaesthetics  in 
Circumflex   nerve,    injuries    to 
Cirrhosis,  ascites  with 


PAGE 

466 

159 

128 

375 
481 
203 
526 
129 
508 

348 

501 
353 
129 

331 


118 
339 
320 
430 
333 
253 
439 
29 
458 
469 
328 
155 

35 
25 
27 
22 
276 
30 
63 
30 
34 
26 

274 
129 

195 

385 

132 

75 

194 

193 
133 
150 
107 
510 
133 

134 
339 
135 
343 
414 

13 

33 

375 


55° 


INDEX    OF    PROGNOSIS 


PAGE 

Cirrhosis,  cj'tology  of  ascitic  fluid  in     92 

—  of  liver  (see  Liver,   Cirrhosis  of)     277 

—  stomach     .... 
Clavicle,  dislocation  of 

—  fracture  of 
CLEFT  PALATE 
Climacteric,  mental  disturbances  of 

—  suicidal  impulses  at 
CLunate,  effects  on  pulmonary  tuber- 
culosis 

—  in  rheumatoid  arthritis 
Climatic   treatment   of  renal   tuber- 
culosis .  . 

Club-foot  (see  Talipes) 

Cocaine  habit,  hopeless  prognosis  of 

—  in  local  analgesia. . 
Cocainism,  chronic     .  . 
Coley's  fluid  in  sarcoma  of  bone 
Colic,  gall-stone 

—  lead  (see  Lead  Poisoning) 

—  renal,  with  appendicitis  .  . 
COLITIS 

—  resulting  from  chronic  appendiciti 
CoUes's  fracture 
COLON,  CARCINOMA  OF 

—  gunshot  wounds  of 
Colonic  etherization  .  . 
Colopexy  in  gastroptosis 
Colostomy,  prognosis  after 

—  for   rectal   cancer    (see    Rectum) 

—  results  in  carcinoma 
Coma  in  diabetes 

—  with  eclampsia     . . 

—  in  exophthalmic  goitre 

—  head  injuries 

—  hemiplegia 
Compensation,     fractures     and     the 

question  of     . . 
Compression  in  abdominal  aneur5-sm 

—  aneurj'sm   of  peripheral   arteries 
Concussion  of  brain  without  signs  of 

injury  . . 

—  the  spine    .  . 
Condylomata,  gonorrhceal 
Confusion,     mental     (see     Mental 

Diseases) 
Confusional  symptoms  in  adolescent 

insanity 
CONGENITAL    DISLOCATION  OF  HIP 

—  hj-dronephrosis 

—  hypertrophy  of  pylorus  . . 

—  and  instinctive  criminals 

—  mental  weakness .  . 

—  stenosis  of  pylorus 

—  syphilis 

hepatic  cirrhosis  of   .  . 

Congestive  dysmenorrhcea  .  . 
Conjunctivitis  with  measles. . 
Constipation  with  chlorosis.. 

—  chronic,  with  asthma 

—  in  melancholia 

—  and  rheumatoid  arthritis 
Contraction  after  bums 
CONTUSIONS,  ABDOMINAL    .  .  .  .  I 
Convulsions  in  bronchopneumonia        119 

—  hemiplegia  . .  .  .  .  .      501 

—  syphilitic  brain  disease    . .  . .     325 

—  uraemic   . .    . .    . .    . .  524 


250 
187,  192 
135 
335 
336 

422 
457 

256 
509 
328 
25 
155 
109 

193 
270 

65 

137 

77 

185 
140 

4 

28 

496 

446 

443 
141 
148 
159 
174 
211 


38 
44 

211 
3o,   481 
203 

321 

334 
142 
•  •  233 
..      487 

■  •      320 

322 

439,  496 

•■      505 

.  .      281 

..      158 

290 

..      131 

93 

■  -      308 
•-      458 

121 


Convulsions  in  whooping-cough     . . 
Copper  salts  in  actinomj^cosis 
Corneal  aiJections  with  measles 

—  ulceration  in  exophthalmic  goitre 
Corriadi's  method  of  wiring  in  abdo- 
minal aneurvsm 

COXA  VARA  ' 

Cretinism 

Criminals,  congenital  and  instinctive 

Crises  of  tabes  dorsalis 

Cuboid,  fracture  of    . . 

Cuneiform  bones,  fracture  of 

Cyanosis  with  measles 

Cyclical  albuminuria 

—  vomiting  of  children,  acidosis  in 
Cyst,  hj'datid 

Cystectomy,  mortality  results  of   .  . 
Cystic  goitre  . . 

—  growths   of  brain    (see    Cerebral 

Tumour) 
Cystitis   (see   Br  adder,   Tuberculosis 
of,  105  ;    Pyelocystitis,  437) 

—  with  cancer  of  bladder    . . 

—  complicating  gonorrhoea  201 

—  and  prostatectomy 

—  tuberculous  (see  Bladder,  Tuber- 

culosis of) 

—  with  vesical  calculus 
Cystoscopy,     importance     in     renal 

growths 
Cysts  of  bone 
— •  ovarian    (see    Ovarian   Tumours) 

—  pancreatic  (see  Pancreatic  Cysts) 
Cytology  of  ascitic  fluid 


PAGE 

543 

9 

290 

173 

38 
143 
324 
320 
508 
182 
182 
290 

12 

5 

232 

105 

199 

124 


104 
203 
410 

105 
96 

252 
109 
381 
383 


"DACTYLITIS,  tuberculous  ..       88 

^^     Davos,  statistics  of  treatment  at  423 


Deafness  from  meningitis 

—  after  mumps 

Death-rate  variations  of  anesthesia 
Decadence,    mental    disturbances   of 
Deciduoma  malignum  (see  Chorion- 
epithelioma)    . . 

Decompression  operation  for  cerebral 

tumour 
Defective  control  of  will 
Defectives,  epileptic. 
Defects,     bodily,     with     congenital 

amentia 
Degeneracy,    delusional    insanity    a 

part  of 
Degeneration,   alcoholic 

—  stigmata  of  . .  .  .  304,  323 
Delhi  boil  (see  Tropical  Diseases)  517 
Delirious  mania  (see  Mental  Diseases) 
Delirium,  epochal,  of  childhood  . . 
• —  '  muttering,'  in  acute  mania  . . 
— •  tremens  (see  Mental  Diseases)  . . 
— •  of  young  children 
Delusional  mania       . .  . .        315,   318 

—  melancholia  . .  .  .  .  .      310 

Delusions  in  epilepsy  .  .  . .      329 

Dementia  (see  Mental  Diseases)      . .      322 

—  following  typhoid  fever..  ..      521 

—  precox  (see  Mental  Diseases)     . .     335 

—  primary      .  .  . .  .  .  .  .      321 

—  puberty  and  adolescent  disturb- 

ances preceding         . .        333,  334 


294 

347 

19 

335 

135 

126 
319 
329 

323 

319 

327 


314 
333 
315 
326 
339 


SUPPLEMENTARY    INDEX 


551 


PAGE 

Dementia,  secondary            . .          . .  322 

Dengue  fever..          ..          ..          ..  517 

Dental  abnormalities  with  migraine  141 

Depression  in  adolescent  insanity  . .  334 

—  influenza    . .          . .          . .          .  .  338 

—  mental  disturbances  of  childhood  333 

—  states  of,  seen  in  private  practice  311 
De  Ribes'  bag  in  placenta  prsevia  . .  400 
Dermatitis  herpetiformis         .  .          - .  386 

—  various  causes  of . .          . .          . .  161 

Dermoid  cysts  (see  Ovarian  Tumours)  381 

Diabetes,  the  acidosis  of      . .          . .  5 

—  bronzed      . .          . .          . .          . .  148 

—  with  cirrhosis  of  liver      . .          . .  279 

—  influenza  with      .  .           .  .          .  .  240 

DIABKTES,  INSIPIDUS              .  .            •  ■  143 

DIABETES,  MELLITUS             .  .            .  .  144 

albuminuria  in           . .          . .  12 

—  —  association  with  arteriosclerosis  82 

pregnancy  in  relation  to     . .  149 

surgical  operations  in          . .  149 

—  pericarditis  with               .  .           .  .  390 

—  pneumonia  with  . .          .  .           .  .  404 

—  pulmonary  tuberculosis  with  .  .  420 
Diabetic  gangrene     . .          . .          . .  197 

—  mental  symptoms            . .          . .  338 

—  neuritis,  muscular  atrophy  due  to  347 
Diaceturia  (see  Acidosis)      . .          . .  5 

—  with  cirrhosis  of  liver     .  .           . .  279 

—  post-auffisthetic    . .          . .          . .  30 

Diarrhoea  in  exophthalmic  goitre   .  .  174 

DIARRHCEA,   INFANTILE  1 50 

—  in  measles. .          . .          . .          . .  290 

Diazo-reaction  in  pulmonary  tuber- 
culosis . .          . .          . .          . .  422 

Diet  in  chlorosis        . .          . .          . .  131 

—  influence  on  eclampsia  . .  .  .13,  14 

—  salt-free,  influence  on  ascites  . .  90 
Dietl's  crises  in  movable  kidney  .  .  343 
Digestion  and  rheumatoid  arthritis  458 
Digitalis  in  mitral  stenosis  . .  .  .  224 
Dilatation  of  cervix  in  eclampsia  .  .  159 

—  stomach     .  .          .  .           .  .           .  .  488 

DIPHTHERIA 1 50 

—  bronchopneumonia   following    . .  119 

—  cardiac  failure  in . .          .  .           .  .  349 

—  with  measles        . .          . .          . .  290 

Diphtheritic  myocarditis,  significance 

of  mitral  systolic  murmur  in  356 

—  neuritis,  muscular  atrophy  from  347 
Dipsomania  (see  Mental  Diseases)  . .  320 
Dislocations      .  .          .  .          .  .          .  .  250 

—  of  hip,  congenital           . .          . .  142 

—  knee           . .          . .          . .          .  .  263 

—  myositis  ossificans  following     . .  359 

—  of  spine     . .          . .          . .          . .  480 

DISSEMINATED  SCLEROSIS   .  .            .  .  153 

Dissemination  of  melanotic  sarcoma  291 
Distention     of     bladder     in     tabes 

dorsalis             . .           .  .           .  .  507 

Diuretics,  influence  in  ascites         . .  89 

Dropsy  in  myocardial  disease         .  .  354 

DRUG  HABITS               154 

Drugs,  morbid  cravings  for  . .          . .  328 

Drimkenness   (see   Mental  Diseases) 

320,  326 

Duct  carcinoma         . .          . .          . .  no 

Dum-dum  fever         . .          . .          . .  517 


PAGE 

DUODENAL  ULCER             .  .                1 5  6,  492 

—  —  after  burns     . .          . .          .  .  121 

—  —  with  chronic  appendicitis     . .  75 

—  —  perforation      .  .          . .          .  .  492 

subphrenic   abscess  following  502 

Duodenum,  ruptures  of       . .           . .  2 
Dupuytren's    fracture,    rareness    of 

good  results    . .          .  .          .  .  175 

Dwarfishness  with  congenital  amentia  324 

DYSENTERY  (see  also   Colitis,    138)  156 

—  amoebic        .  .           .  .          . .         139,  156 

—  tropical  bacillary. .          ..        138,  156 

DYSMENORRHCEA 157 

Dyspepsia,  appendix             . .          74,  495 

—  with  chlorosis       . .          .  .           .  .  131 

Dysphagia  in  laryngeal  tuberculosis  268 

—  after  laryngectomy          .  .           .  .  266 
Dyspnoea    in    impaired    ventricular 

contractility    . .          . .          . ,  353 

—  after  laryngectomy          . .          . .  267 

—  in  papilloma  of  larynx    . .          . .  267 

"pAR  disease,  intracranial  complica- 

-'-^     tions  of                . .          . .          . .  243 

Echinococcal  cyst,  cerebral             . .  125 

ECLAMPSIA 158 

— ■  albuminuria  pireceding   . .          . .  13 

—  foetal  prognosis     .  .          .  .          . .  160 

—  maternal  prognosis          . .          . .  158 
ECTOPIC  PREGNANCY              .  .            .  .  1 60 
ECZEMA    AND    ECZEMATOUS    ERUP- 
TIONS      161 

—  marginatum          . .           .  .           .  .  461 

—  of  nipple,  preceding  cancer       . .  116 
Educability   with   epilepsy   of  early 

childhood         .  .           .  .           .  .  329 

■ —  of  the  feeble-minded       .  .           .  .  323 

Effusion  into   pericardium   in  rheu- 
matic infection          . .          . .  391 

—  pleuritic     . .           . .           .  .           .  .  401 

Egyptian      splenomegaly,      hepatic 

cirrhosis  with..          ..          ..  279 

Elbow,  dislocation  of          . .          . .  250 

—  fracture  of             .  .          . .         184,  191 

— -  tuberculosis  of     . .          . .          . .  88 

Electrical     reactions     in     infantile 

paralysis          .  .           . .          .  .  238 

local  neuritis  . .          . .          . .  378 

muscular  atrophies    .  .          . .  347 

Electro-therapy  in  sciatica  . .          . .  468 

Embolic  gangrene     . .          . .          . .  197 

Embolism,  cerebral  (see  Strokes)   . .  500 

—  pulmonary,  complicating  appen- 

dicitis          . .          . .          . .  59 

following  operation  for  vari- 
cose veins    .  .          .  .          .  .  539 

Embryoma  of  testis  . .          . .          . .  510 

Emetine  treatment  of  amoebic  dysen- 
tery              139,  156 

Emotion  as  a  factor  in  myocardial 

disease             . .          . .          . .  351 

Emotional  influences  in  chlorosis  . .  130 

Emphysema  with  asthma    . .          . .  93 

—  influence  in  bronchitis  ..          ..  118 

—  pneumothorax  and          . .           . .  406 
EMPYEMA         162 

—  of  the  gall-bladder         . .          . .  132 


552                                         INDEX 

OF 

PROGNOSIS 

PAGE 

PAGE 

Empyema,  pneumococcal,  in  children, 

Excitement,    morbid,    with   organic 

relation  to  pericarditis 

389 

brain  disease 

328 

—  pneumothorax  due  to     .  . 

406 

EXOPHTHALMIC  GOITRE       .  . 

170 

Encephalitis,  influenzal 

239 

anaesthesia  in  operation  for .  . 

32 

Endocarditis,  acute  rieumatlc 

453 

complicating  chlorosis 

132 

ENDOCARDITIS,    ULCERATIVE 

164 

danger  signals 

174 

with   malformed   heart 

231 

mental  symptoms  in 

339 

mitral  disease 

221 

prospects  of  relapse  . . 

173 

as  sequel  to  acute  rheumatism 

454 

sequelae 

173 

Endometritis,  gonorrhoeal    . . 

204 

surgical  treatment     . . 

171 

—  sloughing,  and  abscess  (puerperal) 

415 

Exophthalmos,  pulsating,  after  head 

Endothelioma  of  testis 

510 

injury  .  . 

212 

Ensiform  cartilage,  fracture  of      187 

192 

Exstrophy  of  bladder 

98 

Enteric   fever   (see  Typhoid  Fever) 

518 

Extension     method     in     fractures. 

ENTERITIS,  TUBERCULOUS 

165 

Bardenheuer's 

174 

Enterocolitis  in  children 

150 

Extirpation     of     peripheral     aneu- 

Enucleation  of  hydatid  cyst 

233 

rj'sms   . . 

44 

Epidermolysis  bullosa 

386 

Extradural  abscess    . . 

244 

Epididymis,    new    growths    of    (see 

Extrasystolic  type  of  arrhj'thmia  . . 

430 

Testis)              

510 

Extra-uterine  gestation  (see  Ectopic 

Epididvmitis,  gonorrhoeal    .  . 

200 

Pregnancy) 

160 

EPIDIDYMITIS,  TUBERCULOUS 

166 

Eye   affections   with   arteriosclerosis 

84 

with  renal  tuberculosis 

255 

measles 

290 

Epigastric  pain,  pre-eclamptic 

13 

migraine 

141 

Epiglottis,  amputation  in  tuberculosis 

269 

—  complications  of  small-pox 

473 

Epilepsie  larvee 

330 

tabes  dorsalis 

507 

EPILEPSY         

168 

—  symptoms  in  lead  poisoning     .  . 

271 

—  beer-  and  cider-drinking  and     . . 

330 

pre-eclamptic 

13 

—  infantile    convulsions   simulating 

236 

—  mental  unsoundness  with 

329 

"p^CAL  fistula  following  appendix 
operations 

—  minor,  fainting  of  children  due  to 

354 

58 

—  traumatic 

212 

with  psoas  abscess     . . 

413 

Epileptic    convulsions    in    syphilitic 

tuberculous  peritonitis 

394 

brain  disease  . . 

325 

—  impaction  . . 

240 

Epileptics,   recurrent   dislocation   of 

obstruction  due  to     . . 

240 

shoulder  in      .  . 

251 

Face,   actinomycosis  of 

8 

Epiphysitis,   syphilitic 

506 

Facial  expression  in  chronic  alcohol- 

Epithelioma (see  also  Cancer,  Carci- 

ism   .  . 

327 

noma)  of  bladder 

103 

melancholia     . . 

308 

—  after  burns 

121 

mental  diseases 

300 

—  chlorion-  (see  Chorion-epithelioma 

135 

stuporose  insanity     . . 

321 

—  following  ;!;-ray   treatment 

283 

—  nerve,  injuries  to . . 

373 

—  of  jaw 

248 

—  palsy  (see  Nerve  Injuries) 

373 

-^  lip  (see  Lip,  Cancer  of)    . . 

274 

muscular  atrophy  from 

347 

—  tongue  (see  Tongue,  Cancer  of) 

513 

Fainting,     rareness     in     myocardial 

—  vulva  (see  Vulva,  Carcinoma  of) 

541 

disease . . 

354 

Epulis  (see  J  aws.  Tumours  of) 

247 

Fallopian  tube,  chorion-epithelioma 

Equinovarus  (see  Talipes)    . . 

509 

of 

135 

Eruptions,  eczematous 

161 

gonorrhoeal  infection  of 

204 

ERYSIPELAS                  

170 

inflammation  of  (see  Salpin- 

Erythremia (see  Polycythemia)     . . 

407 

gitis)             

463 

Estlander's  operation  for  empyema 

164 

Famfly  history  in  acute  rheumatic 

Ether  anesthesia,  relative  safety  of 

23 

carditis 

450 

—  pneumonia 

36 

cardio-arterial      degeneration 

352 

—  in  relation  to  status  lymphaticus 

30 

mental  disease 

303 

surgical  shock 

34 

phthisis 

421 

■ —  in  spinal  analgesia 

26 

rheumatoid  arthritis 

456 

Etherization,  various  methods  of  . . 

28 

—  susceptibility  to  lead  poisoning. . 

270 

Ethmoidal  sinusitis   . . 

362 

Faucial   inflammation  with  measles 

290 

Ethyl  chloride  anaesthesia,  methods  oJ 

29 

Favus  of  the  scalp    . . 

461 

and   ethyl   bromide,   relative 

Febrile    albuminuria.. 

12 

safety  of      .  . 

22 

—  diseases,  acidosis  in 

5 

Exaltation,  mental  (see  Mental  Dis- 

Feeble-minded 

323 

eases)    . . 

312 

—  Royal  Commission  on  Care  and 

—  as  prelude  to  dementia  . . 

322 

Control  of 

320 

Excited  and  resistive  melancholia  .  . 

310 

Femoral  aneurj'sm     . . 

45 

Excitement  of  mania 

312 

—  artery,  haematoma  of     . . 

206 

—  maniacal,  in  senility 

336 

Femur,  fracture  of   . .          . .        178, 

189 

SUPPLEMENTARY    INDEX 

553 

PAGE 

- 

PAGE 

Femur,  sarcoma  of   . .          . .        107, 

108 

Fractures  of  spine     . . 

480 

Fever,  influence  on  lymphadenoma 

287 

—  spontaneous,  in  tabes     . . 

508 

Fibrillation,   auricular 

432 

—  of  sternum             . .          .  .         187, 

192 

in   myocardial   disease 

357 

—  tarsal  scaphoid     .  . 

182 

Fibro-adenoma  of  breast     .  . 

116 

—  tibia  and  fibula   ..          ..        180, 

190 

Fibroids  (see  Uterus,  Fibroids  of)   .  . 

530 

—  wrist  bones           . .          . .        186, 

191 

—  bleeding,  complicating  pernicious 

Friedreich's  ataxia    . . 

94 

anaemia 

397 

Frohlich's  type  of  hypopituitarism. . 

7 

—  with  cancer 

530 

Frontal  sinusitis  (see  Nasal  Accessory 

Fibromatosis  of  stomach 

498 

Sinusitis) 

361 

Fibromyoma,  ascites  with   .  .          .  .89,  90 

Frost-bite,  gangrene  from    . . 

197 

Fibrosarcoma  of  jaw. . 

247 

Fungating   endocarditis    (see    Endo- 

Fibrosis of  liver,  syphilitic  . . 

281 

carditis,  Ulcerative)  . . 

164 

Fibula,  fracture  of    . .           .  .         180, 

190 

Furunculosis  with  diabetes  . . 

148 

—  sarcoma  of            . .          . .        107, 

108 

Fingers,  fracture  of  . .          . .        186, 

192 

riALL-BLADDER     complications 
of  appendicitis  . . 

—  tuberculosis  of     . . 

88 

62 

Finsen  light  in  lupus  vulgaris 

283 

—  drainage  in  biliary  cirrhosis 

280 

Fistula,  fsecal,  with  psoas  abscess  . . 

413 

—  inflammation     of      (see      Chole- 

 following  appendix  operations 

58 

cystitis) 

132 

—  from  gall-stones   . . 

193 

GALL-STONES                 

193 

—  after  prostatectomy        . .        410, 

412 

—  and  biliary  cirrhosis 

280 

Flutter,   auricular 

432 

—  with  chronic  appendicitis 

75 

Folie  circulaire  (see  Mental  Diseases) 

317 

—  chronic    pancreatitis    simulating 

385 

Food,     excessive,     in     etiology     of 

—  frequent  absence  of  symptoms  .  . 

193 

arteriosclerosis 

82 

—  with  gastric  symptoms  . . 

495 

Foot,  fracture  of  bones  of  .  .        182, 

191 

—  intestinal  obstruction  due  to     . . 

242 

—  tuberculosis  of      . . 

88 

—  operation  mortality 

194 

Foramen  ovale,  patency  of 

230 

Gallop  rhythm  in  contractile  failure 

355 

Foreign   bodies,    intestinal   obstruc- 

Galvano-cautery in  laryngeal  tuber- 

tion due  to     . . 

241 

culosis  . . 

269 

Foetal  prognosis  in  eclampsia 

160 

GANGRENE       

197 

Foetus,    relation   of   albuminuria   of 

—  in  diabetes 

148 

pregnancy  to 

14 

—  following  purpura 

436 

FRACTURES                   

174 

—  hospital  (see  CEdema,  Malignant) 

379 

—  of  astragalus 

181 

—  in    strangulated    hernia            215, 

217 

—  Bennett's  . . 

i85 

Gasserian     ganglion,     removal,     in 

—  of  bones  of  wrist  and  hand 

186 

trigeminal  neuralgia.. 

376 

—  calcaneum 

181 

Gastralgia,   '  appendix  ' 

74 

—  carpal  bones,  with  sprain 

249 

Gastrectomy  in  carcinoma  .  . 

496 

—  carpal  scaphoid    . . 

186 

—  chronic  ulcer 

491 

—  clavicle       . .          . .          . .        187, 

192 

—  plastic  linitis 

498 

—  CoUes's 

185 

Gastric  carcinoma 

486 

—  of  cuboid  . . 

182 

surgical  treatment     .  . 

496 

—  cuneiform  bones  . . 

182 

—  crises  of  tabes      .  . 

508 

—  elbow          . .          .  .          . .        184, 

191 

—  and  duodenal  ulcer  with  chronic 

—  estimation  of  work  capacity  after 

188 

appendicitis     . . 

75 

—  of  femur    .  .           .  .          . .         178, 

189 

—  lavage     in     congenital     pyloric 

—  humerus     .  .          . .          . .         182, 

191 

stenosis            . .          . .        439, 

496 

—  influence  of  age  in  non-operative 

—  symptoms    associated    with    dis- 

treatment 

176 

eases  elsewhere 

494 

—  Jones's  (5th  metatarsal) . . 

182 

of  gall-stones 

I   3 

—  of  metatarsals 

182 

with  movable  kidney 

344 

—  myositis  ossificans  following     . . 

359 

— •  —  of  rheumatic  fever     . . 

449 

—  in  neighbourhood  of  joints 

176 

—  ulcer  (see  Stomach,  Diseases  of) 

487 

—  operative      and      non-operative 

chronic,    operative   treatment 

491 

methods  considered  . . 

174 

connection  with  chlorosis     . . 

132 

—  of  patella  . .          . .          . .        179, 

190 

hffimatemesis  . . 

490 

—  pelvis          . .          . .          . .        188, 

192 

operative    treatment .  . 

488 

urethral  stricture  in 

525 

perforation 

489 

—  Pott's         

180 

— ■  —  subphrenic   abscess   following 

502 

—  —  rareness  of  good  results     175, 

191 

Gastritis  (see  Stomach,  Medical  Affec- 

— of  radius   and  ulna        .  .          185 

191 

tions  of) 

486 

—  report  of  B.M.A.  Committee  on 

175 

Gastro-enterostomy  in  chronic  dila- 

— of  ribs        188, 

192 

tation  of  stomach 

488 

—  scapula       . .          . .          . .         187, 

192 

Gastro-intestinal    hjemorrhage    with 

—  simple 

174 

acute  appendicitis 

64 

—  of  skull 

210 

Gastrojejunostomy  in  carcinoma    . . 

497 

554 


INDEX    OF    PROGNOSIS 


Gastrojejunostomy,     complications 
after 

—  in  gastric  ulcer 

—  injurious   in   gastroptosis 

—  in  plastic  linitis    .  . 

—  pyloric  stenosis    . . 

—  stricture  of  oesophagus  . . 
Gastropexy  in  gastroptosis  . . 
Gastroptosis 

Gelatin    injection    in     abdominal 
aneurysm     . . 

intrathoracic  aneurysm 

General      paralysis       (see      Mental 

Diseases) 
Genu  valgum 

—  varum 
and  rickets 

German  measles  (see  Rubella) 

—  State  sanatoria  for  consumption, 

statistics  of  treatment  at     . . 
Gestation,  extra-uterine  (see  Ectopic 

Pregnancy) 
Gigantism  (see  Acromegaly) 
Gland  clearance  in  cancer  of  lip     . . 

—  enlargement,     disappearance     in 

lymphadenoma 
Glanders,  acute  and  ctronic    .  . 
Glands,  tuberculous  (see  Lj-mphade- 

nitis)     .  . 
Glaucher's     disease     (see     Anaemia, 

Splenic) 
Glioma,  cerebral        . .  . .        124, 

Glucose  treatment  before  anaestheti- 

zation,  influence  of  . . 
Gluteal  aneurysm 
Glycosuria,  alimentary 

—  association  with  arteriosclerosis 
ascites  . . 

—  chronic 

—  in  exophthalmic  goitre    .  . 

—  hemiplegia 

—  hepatic  cirrhosis  .  . 

—  pregnancy 

—  tuberculous  meningitis   . . 
Goelet's  operation  in  movable  kidney 
GOITRE  

—  exophthalmic  (see  Exophthalmic 

Goitre) 
Gonococcal  peritonitis 

GONORRHCEA  

GONORRHCEA  IN  THE  FEMALE 

—  meningitis  as  a  sequel    . . 

—  and  sterility 

—  systemic  manifestations 

GOUT   .  .  

—  with  asthma 

—  in  etiology  of  arteriosclerosis     . . 

—  and  myocardial  disease  . . 

—  rheumatic  . . 

Gouty  diathesis  with  migraine 
Graves's  disease  (see  Exophthalmic 

Goitre) . . 
Gumma,  cerebral 
Gums,  tumours  of     .  . 
Gunshot  wounds  of  abdomen 

head 

heart    .  . 

spine     . . 


210, 


493 
490 

495 
498 
440 

379 
496 

495 

39 

43 

324 


461 
463 

425 

160 
7 

275 

287 


16 
128 

7 

46 

145 

82 

91 

145 

173 

501 

279 

149 

295 

346 


170 
390 
200 
202 
295 
202 
201 
205 

93 

82 

352 

459 

142 

170 
125 
247 
4 
212 
231 
483 


H^MARTHROSIS  of  knee  joint 
Haematemesis  with  acute  appen- 
dicitis 

—  chronic  appendicitis 

—  gastric  ulcer 

—  movable  kidney   .  . 

—  portal  cirrhosis     . .  . .         277, 
Haematocele,     pelvic     (see     Ectopic 

Pregnancy) 
HEMATOMA,  ARTERIAL 
Hcematoporph\T:inuria     from     drug 

poisoning 
Hematuria  in  acute  nephritis 

—  complicating  appendicitis 

—  in  malignant  growths  of  kidney 
Hsemochromatosis      .  .  .  .  91, 

—  cirrhosis  of 

HEMOPHILIA.  

Haemoptysis  with  mitral  stenosis  .  . 
Haemo-retinitis  in  lead  poisoning  . . 
Haemorrhage,  the  anaemia  following 

—  in  biliary  cirrhosis  .  . 

—  in  cancer  uteri,  ligation  of  arteries 

in 

—  cerebral  (see  Strokes) 

—  — •  with  mitral  stenosis  .  . 

—  concealed,  with  abdominal  aneu- 

rysm    . . 

—  dangers  with  vesicular  mole 

—  in  ectopic  gestation 

—  gastro-intestinal,      with      acute 

appendicitis    . . 

—  intracranial   (see   Head   Injuries) 

—  in  lymphadenoma 

—  lymphatic  leukaemia 

—  pernicious  anaemia 

—  portal  cirrhosis     . .  .  .         277, 

—  pre-eclamptic 

—  in  ruptmre  of  uterus 

—  into  spinal  cord    .  . 

—  in  syphilitic  cirrhosis  of  liver    .  . 

—  typhoid  fever 

—  unsuspected,      after     abdominal 

contusions 
Haemorrhagic  purpura  (see  Purpura) 
HEMORRHOIDS 
Hallucinations    of    hearing    at    the 

climacteric 

—  in  melancholia 

Hand,  fracture  of  bones  of  186, 

Hanot's  cirrhosis 

Hartley-Krause  operation  in  tri- 
geminal neuralgia 

Hart's  (Stuart)  method  of  estimating 
acidosis  index 

HEAD  INJURIES  

—  — •  functional  defects  following 
Headaches,  paroxysmal  (see  Migraine) 

—  pre-eclamptic 

Heart,  arrhythmia  not  a  sign  of 
weakness  of    . . 

—  block 

myocardial  disease    . .        353, 

HEART,  CHRONIC  VALVULAR  DISEASES 

— —  relation      of      primary 

disease    of    myocar- 
dium to 

—  complications  in  bronchitis 

—  condition  in  asthma 


263 

64 

75 

490 

344 

279 

160 
206 

155 
363 
65 
252 
148 

279 
207 
223 
271 
15 
280 

529 
500 
223 

37 
342 
160 

64 
210 
287 
272 
397 
279 

13 
535 


520 

I 

43& 

209 

336 
308 
192 
280 

377 

5 

210 

212 

341 

13 

430 
434 
357 
217 


349 
118 

93 


SUPPLEMENTARY     INDEX 


555 


HEART,     CONGENITAL     MALFORMA- 
TIONS OF  

—  defects  of  position 

—  dilatation  of 

—  — -in  exophthalmic  goitre 
— ■  — ■  rheumatic  myocarditis 

—  disease,  albuminuria  in  . . 
anjEsthesia      in      operations 

with 

ascites  of 

gravity  of  failing  contractile 

force . . 

—  —  muscular  (see  Myocardium) 

—  —  in  relation  to  arteriosclerosis 

—  — -  —  chorea 

—  — -  — •  pulse   (see  Pulse) 
spinal  analgesia  in  operation 

with 

—  efiect  of  influenza  on      . . 

—  failure  in  diphtheria 

treatment  in  convalescence. 

—  irregular  (see  Pulse,  Irregularities 

of)         

—  lesions  in  angina  pectoris 
with  pleuijitis  . . 

—  —  pneumonia       . .  .  -         404, 

—  muscle,    assessment    of    working 

capacity  of      . . 

—  rheumatism    of    (see    Rheumatic 

Pericarditis,  etc). 

—  sounds,  weakening  of,  in  contrac- 

tile failure 

—  state  of,  after  anginal  attack    . . 

—  symptoms  in  acute  nephritis     .  . 

chronic  diffused  nephritis     .  . 

interstitial  nephritis 

secondary  ansemia     .  . 

HEART,   SYPHILIS  OF 

—  valvular    disease   of,   relation   to 

pericarditis 

— with  ulcerative  endocarditis 

HEART,  WOUNDS  OF 
Hebephrenic  dementia 
Hedonal,  dangers  of  anesthesia  with 
Hemiplegia  (see  Strokes) 

—  following  infantile  convulsions 

—  in  head  injuries    . . 

—  mental  symptoms  with  . . 

—  relation  to  aphasia 

—  pseudo-bulbar  palsy  due  to 
Henoch's  purpura 

Hepatic  artery,  aneurysm  of 

—  cirrhosis  (see  Liver,  Cirrhosis  of) 
Hereditary  ataxia 

—  traumatic  pemphigus 
Heredity  in  adolescent  insanity    333, 

—  and  arteriosclerosis 

—  epilepsy 

—  haemophilia 

—  influence  of  chlorosis 

—  in  mental  disease. . 

—  mental    and    neurotic,     without 

symptoms 

—  in  migraine 

—  senile  mental  disturbances 
HERNIA  

—  danger  of  strangulation  . . 

—  intestinal  obstruction  due  to     . . 


230 
230 
356 
173 

452 
13 

33 


356 

349 

80 

133 
430 

27 
239 
152 
350 

430 

48 

401 

406 

352 

450 

355 
49 
363 
364 
366 

15 

122 


164 
231 
335 
28 
500 
236 
211 
328 

53 
119 
437 

38 
277 

94 
386 
334 

80 
169 
207 
130 
303 

340 
142 
336 
213 
213 
243 


PAGE 

Hernia,  results  of  operation           . .  213 

HERNIA,  STRANGULATED      .  .            .  .  215 

Herniotomy,  results  of         . .          . .  216 

Heroin  habit  . .          .  .          . .          .  .  155 

Herpetiform  dermatitis        . .          . .  386 

Hiccough     with     post-haemorrhagic 

anaemia            . .          . .          . .  15 

Hip,  congenital  dislocation  of        . .  142 

—  dislocation  of       . .          . .          . .  250 

—  tuberculosis  of  - .  ■  •  •  •  86 
Hodgkin's   disease    (see   Lymphade- 

noma)       . .           .  .      . .           .  .  286 

Homicide,  uncontrollable  impulse  to  320 

Homicidal  impulse  in  melancholia  310 
Hospital     gangrene     (see     CEdema, 

Malignant)       . .           . .          .  .  379 

Hospitals,  risks  of  infection  in       . .  iii 

Hour-glass  stomach  .  .          .  .          . .  491 

Humerus,  fracture  of            .  .           . .  182 

—  sarcoma  of  .  ■  .  ■  107,  108 
Hydatid  cysts  of  pancreas  . .          . .  383 

HYDATID  DISEASE 232 

of  spine           ..          ..        no,  484 

—  mole  (see  Mole)  . .  . .  _  . .  342 
Hydroa  gravidarum  or  gestationis. .  387 
Hydrocephalus  after  meningitis  .  .  294 
Hydrogen    peroxide     in     malignant 

CEdema. .          . .          . .          •  ■  379 

HYDRONEPHROSIS 233 

—  following  impacted  calculus      . .  258 

—  intermittent,  in  movable  kidney  344 

—  pyonephrosis  secondary  to        . .  441 

—  results  of  operations  . .  .  ■  235 
Hydropericardium  . .  . .  390,  391 
Hydropneumothorax . .  ..  ••  407 
Hydrosalpinx . .  . .  .  •  ■  .  464 
Hydrothorax  in  chronic  myocardial 

disease              .  .           .  .           .  •  355 

—  after  ether  inhalation  . .  . .  36 
Hydruria  . .  •  •  •  •  .  •  I44 
Hyperchlorhydria      with      movable 

kidney . .           . .           • •           • •  344 

Hypernephroma  of  kidney  . .  .  .  251 
Hyperpyrexia    in    children,    mental 

disturbance  with        . .           . .  333 

—  rheumatic  fever  . .  .  -  •  .  448 
Hypertrophic  biliary  cirrhosis  .  .  280 
Hypnotics  in  senile  dementia  .  .  337 
Hypochondria  at  the  climacteric  . .  336 
Hypochondriacal  melancholia  .  .  310 
Hypopituitarism  . .  . .  .  •  7 
Hysterectomy  in  cancer  of  body  of 

uterus  . .          . .          . .          . .  530 

—  —  cervix  .  .           . .           .  .          .  ■  528 

—  excessive  vomiting  of  pregnancy  541 

—  fibroids  of  uterus              . .          . .  533 

—  rupture  of  uterus. .          ..          ..  537 

Hysteria,  delusional  insanity  a  part  of  319 

—  disseminated  sclerosis  diagnosed 

as          . .          .  -          ■  •           • •  153 

—  from  spinal  injuries        . .          •  •  480 

TDIOCY          322 

—  after  meningitis        . .           .  .  294 

—  similarity    of    epilepsy    of    early 

childhood  to   . .           .  •           •  ■  329 

Ileus  complicating  appendicitis      .  .  60 

Iliac  artery,  external,   aneurysm  of  46 


556 


INDEX    OF    PROGNOSIS 


PAGE 


Imbecility 

—  analogy    to    adolescent    insanity 

—  moral 

—  '  postponed  ' 

—  similarity    of    epilepsy    of    early 

childhood  to  . . 

Imperforate  anus  (see  Anus,  Imper- 
forate) . . 

Impetigo,  bxillous 

Incontinence  after  prostatectomy 

410,  411,  412 

India,  form  of  endemic  cirrhosis  of 
liver  in 

INFANTILE  CONVULSIONS 

—  diarrhoea    . . 

—  mortality  increased   by   malaria 
INFANTILE  PARALYSIS 

—  splenomegaly 

Infantilism  with  congenital  amentia 
Infants,  acute  arthritis  of 

—  eczema  of . . 

—  pyelitis  of . . 

—  splenic  ansmia  of 
Infarction  of  lung  in  impaired  ventri- 
cular contractility     . . 

Infection   and  rheumatoid   arthritis 

455, 

—  from  unoperated  renal  calculi  . . 
Infections,  neuritis  due  to    . . 
Infective    endocarditis    (see    Endo- 
carditis, Ulcerative)  . . 

Inferior  vena  cava,  wounds  of 
INFLUENZA 

—  cardiac  complications  in 

—  mental  symptoms  from  . . 
Influenzal   meningitis 
Inguinal  hernia 

Injection  treatment  of  intussuscep- 
tion . . 

sciatica 

Injuries  (see  Wounds) 
Innominate  aneurysm 
Inoculation,  antityphoid 
Insomnia  in  mental  diseases 
disturbances  at  climacteric. . 

—  senile  dementia    . . 
Intellect  in   paralysis   agitans 
Interventricular  septiun,  patency  of 
Intestine,    gangrenous,    in    strangu- 
lated hernia    . .  . .        215,   217 

—  gunshot  wounds  of         . .  . .  4 

—  rupture  of  .  .  . .  . .  2 

Intestinal  crises  of  tabes 

—  disinfectants     in     rheumatoid 

arthritis 

—  lavage  in  pernicious  anaemia 
INTESTINAL  OBSTRUCTION  .  . 

and  chronic  appendicitis 

complicating  appendicitis     .  . 

—  —  dangers     of     post-operative 

vomiting 

from  gall-stones 

spinal  analgesia  in     .  . 

—  resection  for  intussusception 
Intermittent  limp  with  arteriosclerosis 
Intoxication,  acid  (see  Acidosis)     . .  5 

—  '  hydatique  '    after  operation  for 

cyst 233 


323 

334 
320 
322 

329 

52 
386 


280 
236 
150 
288 
237 
517 
324 
380 
162 
439 


355 

459 
259 
377 

164 
238 
238 
350 
337 
295 
214 

245 
468 

46 
523 
302 
336 
337 
385 
230 


508 

459 

398 

240 

76 

60 

35 
194 

27 
246 


INTRACRANIAL  COMPLICATIONS    OF 
EAR  DISEASE 

—  haemorrhage  (see  Head  Injuries) 
Intratracheal  insufflation     . . 
Intrathoracic   aneurysm   (see  Aneu 

rysm.   Intrathoracic) 
Intubation  or  tracheotomy  in  diph 

theria   . . 
INTUSSUSCEPTION      .  . 

—  chronic 

—  Henoch's  purpura  with  . . 

—  injection  of  water  in 

—  results  of  operation 
Iodide    of    potassium,    influence    in 

actinomycosis 

test    in    nephritis,    technique 

Iodides  in  chronic  alcoholism 

—  spinal  tumours     .  . 

—  syphilis 
Iodine,  nascent,  in  laryngeal  tuber 

culosis 

—  —  in  lupus  vulgaris 
Iron  in  chlorosis 

—  pernicious  anemia 
Irritability,     a    favourable    sign    in 

melancholia     .  . 
Ischemic  contracture  (see  Muscular 
Atrophies) 

TACKSONIAN  epflepsy  in  syphfl 

^      itic  brain  disease 

Jaundice,  association  with  ascites 

—  complicating  appendicitis 

—  in  congenital  syphilitic  cirrhosis 

of  liver 

—  eclampsia  . . 

—  liver  atrophy 
• —  pernicious  anaemia 

—  portal  cirrhosis     . . 

—  puerperal  sepsis   . . 
Jaw,  actinomycosis  of 

—  dislocation  of       .  . 
JAWS,  TUMOURS  OF 
Jejunal  ulceration  after  gastrojeju 

nostomy 
Jejunostomy  in  gastric  carcinoma 

—  plastic  linitis 
Joint   affections,   muscular   atrophy 

from . . 

—  —  of  tabes 
Joints,  fractures  in  neighbourhood  of 
JOINTS,  INJURIES  OF 
— •  involvement  in  osteomyelitis 
■ —  syphilitic    . . 

—  tuberculosis  of  (see  Arthritis) 
Jones's  fracture  (5th  metatarsal) 

XAHLER'S  disease 
Kala-azar 

—  endemic    cirrhosis    of    Calcutta 

allied  to 
Katatonic  dementia  . . 
Keloid  after  bums     . . 
Kidney,    calculus    of,    with    gastric 

symptoms 
complicating  vesical  calculus 

—  —  —  carcinoma 


109 
517 

280 
335 

121 

495 

96 

104 


SUPPLEMENTARY    INDEX 


557 


Kidney  complications,  anaesthesia  in 

operations  with       . .          .  .  33 
ascites  of         . .          . .          . .  89 

—  function,  methods  of  estimation  of  367 

—  gunshot  wounds  of         . .          . .  5 

—  hydronephrotic     (see     Hydrone- 

phrosis)           . .          . .          . .  233 

—  lesions  with   appendicitis           .  .  65 

in  etiolog>'  of  arteriosclerosis  82 

— •  - —  high  arterial  tension  with    . .  79 
KIDNEY,     MOVABLE     (see    Movable 

Kidney)        343 

Dietl's  crises  in         . .          . .  343 

gastric  and  mental  symptoms  in  344 

intermittent  hj^dronephrosis  in  344 

—  —  results  of  operation  . .          .  .  344 
KIDNEY,  NEW  GROWTHS  OF              .  .  251 

age  factor  in        . .          . .  253 

duration     and     operative 

results    . .          . .          . .  252 

—  operations  on  (see  Hydronephrosis 

Pyelocj-stitis,   Pyonephrosis) 

KIDNEY,  POLYCYSTIC              .  .            .  .  254 

—  rupture  of             .  .          . .           . .  3 

KIDNEY,  TUBERCULOSIS  OF               .  .  254 

—  —  results  of  medical,  etc.,  treat- 

ment           . .          . .          . .  256 

results  of  operation   .  .           . .  257 

spontameous  cure  of  . .          . .  255 

with  vesical  tuberculosis      .  .  105 

relation  to  epididymitis       . .  166 

KIDNEY  AND  URETER,  CALCULUS  OF  258 

—  —  —  anuria  from          .  .           .  .  261 

— asepsis  and  infection       .  .  259 

— •  results  of  operation        . .  260 

recurrence. .          . .           .  .  261 

size  and  number  . .          . .  258 

unilateral  and  bUateral  .  .  259 

Kinks,  intestinal,  and  chronic  appen- 
dicitis  . .           . .          . .          . .  76 

complicating  appendicitis     . .  61 

obstruction  due  to     .  .          .  .  241 

Knee,  internal  derangement  of      . .  263 
—  results  of  operation        . .  264 

—  joint,   fracture  involving          179,  190 
KNEE-JOINT,  INJURIES  OF    .  .            .  .  262 

—  perforating  wounds  of     .  .          .  .  264 

—  ruptured  ligaments  of     .  .          . .  263 

—  tulDerciilosis  of       .  .          . .          .  .  87 

Kocher's    operation    in    cancer    of 

tongue 

hernia  . .  . .  . .        213 

Korsakow's  psychosis  in  pohmeuritis 
Kraepelin's  classification  of  dementia 

praecox 

manic-depressive  insanity    .  . 

Krokiewicz's    sheep-brain    emulsion 
in  tetanus 


T  ABOUR,  effect  of  fibroids  on     . . 
—  premature,     induction      it 

mental   disease   of  preg 

nancy 
—  rupture  of  uterus  in 
Lactation,  cancer  of  breast  during 
Lactational  insanity    . . 
Laennec's  cirrhosis    . . 


514 
214 

377 

335 
316 

513 

533 


332 
535 
no 
332 
277 


Laminectomy     for     paraplegia     in 

spinal  caries    . .          . .          . .  478 

—  spinal  injuries       . .          . .          . .  482 

tumours           . .          . .          . .  484 

Lancereaux's    gelatin    injection    in 

abdominal  anemrysm  . .  39 

—  —  —  intrathoracic  aneurysm  . .  43 
Lane's  operation  for  cleft  palate  .  .  136 
Langenbeck's     operation     for     cleft 

palate  . .          . .          . .          . .  136 

Lardaceous  disease,  ascites  of        . .  89 

Laryngeal  complications  of  measles  290 

—  —  scarlet  fever    .  .          . .          .  .  467 

—  crises  of  tabes      . .          . .          . .  508 

Laryngectomy     and     laryngostomy 

in  tuberculosis            .  .           .  .  269 

—  results  of,  in  cancer  .  .  .  .  266 
LARYNX,  CARCINOMA  OF  .  .  .  .  265 
th\TO-fissure  in          . .          .  .  265 

—  chicken-pox  invading  .  .  . .  129 
LARYNX,  PAPILLOMA  OF                    .  .  267 

—  scald  of      .  .           . .           .  .          .  .  121 

LARYNX,  TUBERCULOSIS  OF             .  .  268 

—  ulceration  of,  in  typhoid  fever  .  .  520 
Lateral  sinus  thrombosis  . .  .  .  244 
Lavage  in  congenital  pyloric  stenosis 

439,  496 

LEAD  POISONING 270 

and  arteriosclerosis    .  .           .  .  81 

—  —  mental  symptoms  of . .  . .  340 
Leishmaniasis              . .           .  .          . .  517 

LEPROSY            '271 

Lethargic   symptoms   in    adolescent 

insanity            334 

Leucoplakia  vulvae,  precancerous    .  .  541 

LEUCOCYTH^MLA 271 

—  chloroma    . .          . .          . .           .  .  274 

—  lymphatic              . .          . .          . .  272 

—  medullary              . .          . .           .  .  273 

—  mixed   forms         . .          .  .           .  .  274 

LICHEN  PLANUS          274 

Ligament  of  knee,  rupture  of        .  .  260 

Ligature  in  abdominal  aneurysm   .  .  38 

—  aneurysm   of  peripheral    arteries  44 

—  operation  in  exophthalmic  goitre  172 
Lightning  pains  of  tabes  .  .  .  .  506 
Linitis,  plastic            .  .           .  .          .  .  498 

LIP,   CANCER  OF          274 

prospects  of  cure  and  reciur- 

rence            . .          . .          . .  275 

results  of  operation  . .          . .  274 

Litholapaxy  in  presence  of  bladder 

complications .  .           .  .           .  .  96 

Lithotomy  and  litholapaxy,  results  of  97 

Liver  abscess,   amoebic          .  .         140,  156 

LIVER,  ACUTE  YELLOW  ATROPHY  OF  276 

•  special  danger  signals     .  .  277 

LIVER,   CIRRHOSIS  OF             .  .            .  .  277 

—  —  biliary  .  .           .  .           .  .           .  .  280 

—  —  Indian  form  of           .  .          . .  280 

—  —  parasj'philitic.  .           ..          ..  281 

portal  .  .           .  .          . .          . .  277 

jaundice  and  ascites  of  . .  278 

syphilitic          .  .           .  .           .  .  280 

—  diseases,  ascites  of  .  .  . .  89 
glycosuria  associated  with  . .  145 

—  hydatid  disease  of          . .          . .  232 


558 


INDEX     OF    PROGNOSIS 


Liver  rupture  of 

—  stab  and  gunshot  wounds  of  . . 
Local  analgesics,  relative  safety  of.  . 
Locomotor   ataxy   (see   Ataxias,   93, 

and  Tabes  Dorsalis,   506) 
Lorenz's     operation     in     congenital 

dislocation  of  hip 
Ludwig's  angina 
Lumbar  puncture  in  meningitis 
Lunacy  (see  Mental  Diseases) 
Limatics,  tuberculosis  in     . . 
Lung,  actinomycosis  of 

—  affections  with  measles  . . 

—  changes  in  impaired  ventricular 

contractility    . . 

—  collapse  of,  bronchiectasis  due  to 

—  diseases,  relation  of  influenza  to 
LUPUS,  ERYTHEMATOSUS      .  . 
LUPUS  VULGARIS 

—  —  dangers  of  x  rays  in  .  . 

—  —  excision  and  Finsen  light  in 
LYMPHADENITIS,   TUBERCULOUS     .  . 

—  medical  and  general  treatment  .  . 

results  of  operation  . . 

LYMPHADENOMA 

—  medical  treatment 

—  necessity    for    microscopical    ex- 

amination 

—  surgical  treatment 
Lymphatic  dissemination  of  melan- 
otic sarcoma  .  . 

—  fistula     (see     Thoracic     Duct, 

Wounds  of)     . . 
Lymphatic  leuksemia 
Lymphatism,  relation  of  anaesthetics 

to  


lyrACEWEN'S       acupuncture 

abdominal  aneurysm 
Madura  foot  (mycetoma) 
Magnesia,  calcined,  in   papilloma  of 

larjmx  . . 
Magnesium    sulphate    injections 

puerperal  sepsis 

in  tetanus 

MALARIA  

—  chronic,  ascites  due  to    . . 
Malarial  neuritis,  muscular  atrophy 

from 
Malignant  disease,  ascites  with 

after  duodenal  ulcer . . 

vesicular  mole 

hydronephrosis  with.  . 

of  hip   . . 

larynx 

pericarditis  with 

of  stomach 

tongue . . 

—  endocarditis    (see    Endocarditis, 

Ulcerative) 

—  —  as  sequel  to  acute  rheumatism 

—  goitre 

—  growths  of  bladder  (see  Bladder) 
jaw 

kidney . . 

originating  in  a  mole 

of  prostate 

—  melanoma 


PAGE 

2 

4 

25 


142 
124 
295 
296 
420 

9 

289 

355 
117 
239 
281 
282 
283 
283 
284 
284 
285 


286 
287 

291 

513 
271 

29 


38 
288 

267 

418 
513 


347 

89 

493 

343 

233 

274 

265 

390 

496,  498 

513.  517 


164 
454 
199 
100 
247 
251 
342 
408 
291 


Malignant     oedema     (see     (Edema, 

Malignant)       .  .          . .          . .  379 

—  ovarian    tumours..          ..          ..  381 

—  pustule  (see  Anthrax)      . .          . .  51 

—  scarlet  fever         . .          . .          . .  465 

—  stricture  of  oesophagus  . .  . .  379 
Malta  or  Mediterranean  fever  . .  517 
Mania  (see  Mental  Diseases)           . .  312 

—  a  potu       . .          . .          . .          . .  326 

—  following  typhoid  fever  . .          . .  521 

—  and  melancholia,  relation  between  316 
Manic-depressive  Insanity  (see  Mental 

Diseases)          . .          . .         305,  316 

Marie's  cerebellar  type  of  ataxia  . .  94 
Mark,    the    pugilist's,    shock    from 

blow  on           . .          . .          . .  I 

Marriage  of  epileptics          .  .          . .  168 

—  haemophilics          . .          . .          . .  209 

—  influence  in  chlorosis      . .          . .  131 

—  mental  heredity  and      . .          . .  340 

—  after  syphUis        . .          . .          . .  506 

Mastitic  form  of  carcinoma. .          . .  no 

Mastitis,  chronic        . .          .  .          . .  116 

Masturbation  in  mental  disease     . .  339 

Matas'  operation  in  aneurysm  . .  44 
Maxilla,     removal     for     malignant 

growth . .          . .          . .          . .  248 

Maxillary    sinusitis,    various    opera- 
tions for          . .          . .          . .  360 

Maydl's   operation   in   exstrophy   of 

bladder             . .          .  .           .  .  99 

MEASLES          288 

—  age  influence  on  mortality  in    . .  288 

—  bronchiectasis  as  a  sequel         . .  116 

—  complications        . .          . .          . .  289 

—  influence  of  social  status  . .  290 
Meckel's    diverticulum,    obstruction 

due  to . .          . .          . .          . .  242 

Mediterranean  fever..          ..          ..  517 

Medullary  leukaemia    ...          ..          ..  273 

Melaena  with  acute  appendicitis     . .  64 

Melancholia  (see  Mental  Diseases)    . .  305 

—  with  adolescent  insanity           . .  334 

—  agitated,  at  the  climacteric      . .  336 

—  following  typhoid  fever  . .  . .  521 
influenza          . .          . .          . .  338 

—  and  mania,  relation  between    . .  316 

—  in  senile  mental  disturbances  . .  336 
MELANOTIC  SARCOMA  .  .  .  .  29 1 
principles    and    prospects    of 

operation     . .          . .          . .  292 

Melanuria        . .          .  .          . .          . .  91 

Membranous  colitis  . .          . .          . .  137 

—  dysmenorrhoea     . .          . .          . .  158 

—  gastritis      . .          .  .          . .          . .  486 

Memory,  affection  of  in  chronic  alco 

holism  . .  . . 

—  affected  in  epilepsy 
after  influenza 


327 

330 

338 

—  prodigious,  with  congenital  amentia  324 


Mendez's  serum  in  anthrax. 

Meningism 

MENINGITIS 

—  complicating  typhoid  fever 

—  following  ear  disease 

—  meningococcal 

mental  after-effects  . . 

—  pneumococcal 


51 
295 

294 
520 
245 
294 
294 
294 


SUPPLEMENTARY    INDEX 

559 

PAGE 

- 

PAGE 

Meningitis,  relation  to  aphasia 

53 

Mental     diseases,      mania,      simple 

—  syphilitic    . . 

326 

exaltation    . . 

312 

—  tuberculous 

295 

statistics  of  all  forms     . . 

315 

movements     in,      simulating 

manic-depressive  insanity  305 

316 

chorea 

134 

manner  of  onset 

299 

Meningococcal  meningitis    . . 

294 

—  • —  masturbation  in 

339 

Menopause,  fibroids  and  the 

535 

melancholia 

305 

—  influence  on  epilepsy 

168 

delusional    and   homicidal 

310 

—  mental  symptoms  at 

336 

duration  of 

307 

Menorrhagia  with  uterine  fibroids  .  . 

531 

excited  and  resistive 

310 

Mental  change  in  epilepsy    .  . 

169 

favourable  prognosis  of  . . 

306 

from  lead  poisoning  .  . 

271 

indications     of     improve- 

—•  condition  in  chorea 

134 

ment 

307 

—  deficiency  following  meningitis. . 

294 

hypochondriacal  . . 

310 

MENTAL    DISEASES    .  . 

296 

from  influenza 

338 

adolescent  insanity,  facial  ex- 

 periodicity  and  recurrence 

309 

pression  in . . 

300 

premonitory  symptoms  .  . 

311 

tendency  to  periodicity  in 

318 

recoveries  in  private  prac- 

 recurrence 

334 

tice 

311 

age  and  temperament  in     . . 

305 

suicidal  impulse  in        309 

312 

alcoholic    dementia    and    de- 

 unfavourable  indications 

308 

generation   . . 

327 

morbid  cravings  for  drugs  . . 

328 

alcoholism  and  alcoliolic  disease 

326 

paranoia,  facial  expressions  in 

301 

— acute 

326 

phthisical  insanity    . . 

338 

— chronic 

327 

of  puberty  and  adolescence 

333 

dipsomania 

320 

puerperal  insanity 

331 

epilepsy  and 

331 

intercurrent     diseases 

'  respectable  excess  ' 

327 

with . . 

331 

•  amentia 

322 

rarer    etiological    and    clinical 

—  —  anatomical  and  physiological 

forms 

337 

relations  of  brain  to 

296 

response  to  treatment 

302 

associated  with  childbirth 

331 

Scottish  Board's  statistics  of 

causation  and  prognosis 

301 

recoveries,  etc. 

298 

of  childhood      . . 

333 

states   of  depression  seen  in 

Clouston's  law  of  heredity  in 

305 

private  practice 

311 

• conditions   of   confusion    and 

marked  and  regular  alter- 

stupor 

321 

nation  and  periodicity 

317 

— congenital  weakness 

322 

mental  enfeeblement 

322 

conditions  of  mental  exaltation 

312 

stigmata  of  degeneration    304, 

322 

simple       depression      and 

syphilitic 

325 

elevation 

305 

—  disturbance  with  movable  kidney 

344 

—  —  danger  of  recurrence . . 

303 

—  hospital,  response  to  treatment  in 

302 

—  —  defective  control,  insane  impulse 

319 

numbers  and  age  of  patients 

'  delirious  mania ' 

314 

now  sent  to 

298 

delirium  tremens 

326 

—  inhibition  in  chronic  alcoholism 

327 

the  disturbances  of  decadence . . 

335 

medico-legal  aspect  of 

321 

dementia 

322 

non-development  of  . . 

320 

dementia  prascox 

335 

—  and   neurotic    heredity,    without 

—  —  epileptic 

329 

symptoms 

340 

epochal  disturbances 

332 

—  stigmata  with  congenital  amentia 

324 

facial  expression  in  . . 

300 

—  stress  in  etiology  of  arteriosclerosis 

82 

factors   influencing   prognosis 

296 

—  symptoms  in  acute  rheumatism 

'  foUe  circulaire  ' 

317 

and  chorea 

339 

general  paralysis 

324 

Bright's  disease 

338 

syphilis  as  cause 

324 

diabetes 

338 

heredity  in      . . 

303 

from  influenza 

337 

idiocy  . . 

322 

of  lead  and  arsenical  poisoning 

340 

importance  of  time  element  in 

300 

with  mumps  .  . 

346 

insomnia  in    . . 

302 

in  myxoedema 

339 

lactational  insanity  . . 

332 

neuritis 

377 

mania    . . 

312 

organic  brain  diseases 

328 

acute 

313 

rheumatic  fever 

449 

as  prelude  to  dementia 

322 

syphilitic 

325 

from  syphilis  . . 

326 

Mercurial  stomatitis  .  . 

499 

a  potu 

326 

MERCURTAT.TSM           

341 

— chronic 

315 

Mercury  treatment  of  cardiac  syphilis 

123 

— delusional  . .          .  .          315 

318 

syphilis 

503 

good  and  bad  indications 

314 

syphilitic  jaundice     . . 

276 

56o 


INDEX    OF    PROGNOSIS 


PAGE 

Mesothorium  in  cancer  of  uterus  . .  529 
Metabolic    S5'stemic    lesions,     anaes- 
thesia with      .  .          . .          .  .  33 

Metacarpals,  fracture  of  .  .  186,  192 
Metatarsals,  fracture  of  .  .  182,  191 
Mexico,    endemic    form    of    hepatic 

cirrhosis  in      . .           .  .          . .  280 

MIGRAINE         341 

Milk  diet,  influence  on  eclampsia  . .  13 

jMitral  and  aortic  disease,  combined  228 

• —  regTirgltation          •  •          •  •           •  .  218 

—  stenosis       .  .          ■ .          •  ■          ■ .  220 

—  • —  effect  of  treatment     .  .           .  .  223 

—  —  rheumatic        .  .          .  .           .  .  453 

—  systolic  murmur,   significance  in 

myocardial  disease     . .          . .  356 

MOLE,    SIMPLE             342 

MOLE  VESICULAR 342 

—  —  chorion-epithelioma  following 

135,  343 

complications  and  mortality  of  343 

effect  on  fertility       . .          . .  343 

Monomania     ..          ..          ..          ..  318 

Moore's  method  of  wiring  in  abdo- 
minal anemrysm         . .          . .  38 

Moral     deterioration     in     chronic 

alcoholism       . .          .  .          . .  327 

—  imbecility  . .         . .          . .          . .  320 

Morphia   a   cause   of   post-operative 

vomiting          35 

—  with  general  anaesthesia            . .  24 

—  habit           . .          . .          . .          .  .  154 

—  influence  on  surgical  shock  .  .  34 
Morton's  fluid  in  spina  bifida         .  .  476 

MOVABLE  KIDNEY 343 

Dietl's  crises  in          .  .           .  .  343 

intermittent  hydronephrosis  in  344 

results  of  operation  . .          . .  344 

Mucinoid  ascites        . .          . .          . .  92 

Multilobular  cirrhosis  of  liver         . .  277 

MUMPS              346 

Mundesley  Sanatorium  for  consump- 
tion, statistics  of  treatment  at  427 

Murray's    proximal    compression    in 

abdominal  aneurysm            .  .  38 

MUSCULAR  ATROPHIES          .  .            .  .  347 

—  atrophy,  arthritic            . .          . .  347 

in  infantile  paralysis. .          . .  237 

ischaemic          . .          . .          . .  347 

myopathic       ..          ..          ...  347 

neuritic            . .          . .          . .  347 

progressive      .  .          . .          . .  348 

pathological     identity     of 

bulbar  palsy  with       ..  119 

Musculospiral  nerve,  injuries  to      .  .  376 

—  paral3'sis  in  fracture  of  humerus  183 
MYASTHENIA  GRAVIS            .  .           •  •  348 
Mycetoma        .  .          . .          .  .          . .  288 

MYCOSIS  FUNGOIDES               .  .            •  •  349 

Myelitis  following  spinal  injuries    .  .  480 

Myelocythaemia          .  .           .  .          .  -  273 

Myeloid  sarcoma        .  .           .  .          .  .  107 

—  tumour  of  jaw      .  .          .  .          .  .  247 

Myeloma,  multiple    . .          . .          . .  109 

—  Bence-Jones's  proteinuria  in     . .  13 
Myocardial  disease  with  aortic  regur- 
gitation       .  .          .  .          . .  226 


Myocardial  disease,  pulse  irregularity 

in          . .          . .          . .          . .  430. 

in  angina  pectoris        . .          . .  48- 

—  syphilis       .  .          .  .          . .          . .  122 

—  and  valvular  disease,  relation  of  218 
Myocarditis,  acute  rheumatic              .  .  452 

—  pericarditis  with  . .  . .  388,  39a 
Myocardium,  assessment  of  working 

capacity  of     .  .          .  .          . .  352 

MYOCARDIUM,  PRIMARY  DISEASE  OF  349 

—  —  —  acute  infections    . .          . .  349 

in  chronic  alcoholism     .  .  350 

diphtheria              .  .          . .  349 

—  —  —  functional  injury  shown  at 

examination       . .          .  .  352 

—  —  —  impairment  of  contractility 

of  ventricles       .  .          . .  353 

—  —  —  impairment  of  tonus          . .  356 

influence  of  treatment    . .  358 

likelihood  of  sudden  death  358 

—  —  —  the  morbid  process  present  349 

—  —  —  significance  of  mitral  sys- 

tolic murmru:  in          . .  356 
S3'philitic 351 

—  progressive  degenerations  of  .  .  350 
Myomectomy  for  uterine  fibroids  .  .  534 
Myopathic  muscular  atrophy  .  .  347 
Myopathies  (see  Muscular  Atrophy)  347 
Myositis,  interstitial,  atrophy  due  to  347 
MYOSITIS  OSSIFICANS  .  .  •  ■  358 
Myxoedema,  mental  symptoms  in  . .  339 

"NJ  AIL-EXTENSION     method     in 

fractures,    Steinmann's            ..  174 

Narath's  operation  for  ascites         . .  279 

Nasal    abnormalities   with   migraine  141 

NASAL  ACCESSORY  SINUSITIS           .  .  359 

—  —  —  ethmoidal  and  sphenoidal  362 

—  —  —  frontal  sinus         . .           . .  361 

—  —  —  maxillary  sinus  . .  .  .  360 
— vaccine  treatment  in       . .  359 

—  treatment  in  asthma      . .          . .  93 
Nascent  iodine  in  laryngeal  tubercu- 
losis     . .          . .          . .          . .  268 

lupus  vulgaris            . .          . .  282 

Nausea,       with       post-haemorxhagic 

anaemia            . .          . .          . .  15 

Neck,  fracture  and  dislocation  of  . .  481 

Necrosis  in  osteomyelitis     . .          .  .  380 

—  typhoid  fever       . .          .  .          .  .  520 

Negroes,  fatality  of  small-pox  in    . .  472 

Neosalvarsan   treatment   of  syphilis  503 

Nephrectomy  for  calculus    . .          .  .  261 

—  malignant  growths          .  .          . .  252 

—  renal  tuberculosis            . .          . .  257 

—  tuberculosis  of  bladder  . .  . .  106 
NEPHRITIS 362 

—  acute          . .          . .          . .          . .  362 

—  albuminuria  apart  from             . .  11 

—  after  burns            .  .          . .          . .  120 

—  chronic  diffused   .  .          . .          . .  364 

—  —  interstitial       . .          .  .          . .  365 

methods  of  estimation  of 

renal  function  .  .          .  .  367 

—  —  pulmonary   tuberculosis  with  420 

—  complicating  typhoid  fever       .  .  520 

—  with  diabetes  mellitus     .  .          . .  12 

—  mental  symptoms  with  . .          . .  338 


SUPPLEMENTARY    INDEX 

561 

Nephritis,  pericarditis  with  . . 

I'AGE 

/^BESITY,  with  diabetes  or  glyco 
^     suria 

PAGE 

—  pleuritis  with 

to  I 

146 

—  pneumonia  with  . . 

404 

—  and  myocardial  disease  .  . 

352 

—  with  scarlet  fever 

466 

Obstruction,   intestinal 

240 

—  uraemia  of . . 

524 

Obstructive  biliary  cirrhosis 

280 

Nephrolithotomy,  results  of 

260 

Obturator  method  in  cleft  palate  . 

137 

Nephropexy     in     movable     kidney, 

Occupational  influences  in  chlorosis     130 

end-results  of .  . 

344 

CF-dema  of  acute  nephritis  . .      363  et  seq. 

Nephrotomy    and    nephrectomy    in 

—  feet,  association  with  ascites     . 

91 

pyelocystitis 

438 

—  legs  with  ascites  of  cirrhosis 

278 

pyonephrosis  .  . 

441 

biliary  cirrhosis 

280 

—  nephropexy,      etc.,      in      hydro- 

(EDEMA, MALIGNANT 

379 

nephrosis 

235 

—  in  myocardial  disease 

3.54 

NERVE  INJURIES 

368 

—  pre-eclamptic 

13 

brachial  plexus 

374 

—   pulmonary,  after  ether  inhalation       36 

—  —  '  bridging '  operations 

371 

in  impaired  ventricular  con 

—  circumflex  and  ulnar 

375 

tractility 

355 

facial    . . 

373 

GEsophagoscope,  use  in  stricture     . 

379 

with  fractured  skull  . . 

212 

(ESOPHAGUS,  STRICTURE  OF 

379 

injury  in  continuity  .  . 

368 

Old  age,  mental  disturbances  of    . 

335 

— — terminal  branches 

373 

Olecranon,  fracture  of 

185 

musculospiral . . 

376 

Omnopon  with  general  anassthesia  . 

25 

primary  suture 

369 

Oophorectomy,     double,     in     osteo 

- 

recurrent  laryngeal   .  . 

374 

malacia             .  .           .  . 

380 

secondary  suture 

370 

Oophoritis  and  salpingitis    .  . 

463 

—  operations  in  sciatica     . . 

468 

Open-air  treatment  of  phthisis 

419 

—  superior     laryngeal,      operations 

—  —  recurrent  cancer 

114 

on  in  tuberculosis     . . 

269 

Operation,  limits  of  anaemia  justify 

- 

—  syphilis 

505 

ing 

16 

—  tonics  in  melancholia 

308 

Ophthalmia,  gonorrhoeal 

201 

Nervous    influences    in    rheumatoid 

Ophthalmoscopic    tests    in    chronic 

arthritis            .  .           .  -        457, 

460 

nephritis 

366 

—  lesions,  dangers  of  anaesthetics  in 

33 

Opium  alkaloids  with  general  anaes 

- 

—  symptoms  of  exophthalmic  goitre 

173 

thesia   . . 

25 

movable  kidney 

344 

—  habit          

328 

—  system,  affection  in  rickets 

46r 

—  poisoning  .  . 

154 

in  diabetes 

148 

Opsonic  index  of  ascitic  fluid 

92 

—  tone,  lowering  by  influenza 

338 

Optic  complications  of  tabes  dorsalis     507 

Neuralgia,  sciatic  (see  Sciatica) 

467 

Orchitis,  atrophy  of  testicle  after    . 

•      346 

NEURALGIA,    TRIGEMINAL   .  . 

376 

—  from  mumps 

346 

Neurasthenia,  from  spinal  injuries.  . 

480 

—  tuberculous  (see  Epididymitis)  . 

.      166 

Neurectomy  for  trigeminal  neuralgia 

376 

Organo-therapy  in  Addison's  disease         9 

Neuritic  Muscular  Atrophy    . . 

347 

Orthopa3dics  in  peroneal  atrophy   . 

•      348 

NEURITIS          

377 

Os  magnum,  fracture  of       . . 

.      186 

—  peripheral,  in  chronic  alcoholism 

327 

Ossification,  muscular  (see  Myositis 

—  sciatic  (see  Sciatica) 

467 

Ossificans) 

•      358 

Neurological   conditions  in  relation 

OSTEITIS  DEFORMANS 

•      380 

to  mental  disease 

304 

Osteoma 

106 

Neuroses  of  childhood,   mental  dis- 

OSTEOMALACIA             

■      380 

turbance  with 

333 

OSTEOMYELITIS 

•      380 

—  liability  to  be  transformed  into 

—  pericarditis   complicating 

390 

mental  attacks 

341 

Osteotomy  in  coxa  vara 

143 

Neurosis  underlying  dysmenorrhoea 

157 

Otitis  media  complicating  scarlet  fev 

er  467 

Neurotic  and  mental  heredity,  with- 

 whooping-cough   .  . 

543 

out  symptoms 

340 

intracranial  complications  0 

f     243 

New-born,   ophthalmia  of    .  . 

201 

with  measles  . . 

290 

—  pemphigus  of 

386 

—  after  mumps,  deafness  due  to    . 

347 

Nipple,  Paget's  disease  of    .  . 

116 

OVARIAN    TUMOURS 

381 

Nitrites  in  high  arterial  tension 

80 

ascites  due  to 

89,   90 

—  significance   of  effect   in   angina 

—  —  malignant 

382 

pectoris 

40 

—  —  and  pregnancy 

382 

Nitrogen  excretion,  indications 

6 

rupture  of 

382 

Nitrous    oxide    anaesthesia,    relative 

Oxygen  in  myasthenia  gravis 

348 

safety  of      .  . 

23 

—  treatment   of  malignant   cedem< 

1      379 

in  spinal  analgesia 

26 

Nodules,  significance  in  acute  rheu- 

pAGET'S    disease      fsee     Osteitis 

matic  pericarditis 

450 

Deformans) 

380 

Novocain  in  local  analgesia . . 

25 

of  the  nipple  . . 

116 

36 


562 


INDEX    OF    PROGNOSIS 


PAGE 

Pain,  cardiac,  in  myocardial  disease  353 

Palate,  cleft  (see  Cleft  Palate)       . .  135 

Pallor  in  abdominal  contusions     . .  2 

Pancreas,  abscess  of .  .           .  .           .  .  385 

—  rupture  of             .  .           .  .           . .  3 

PANCREATIC  CYSTS 383 

PANCREATITIS              384 

—  with  mumps         .  .           .  .           .  .  346 

Papilliferous  goitre    . .          . .          . .  199 

Papilloma  of  bladder  100 

—  kidney        . .          . .          . .           . .  251 

—  larynx  (see  LarjTix)        . .          . .  267 

—  ovarian,  ascites  with    .  .  .  .      89,  90 

—  of  tongue  . .          .  .          . .          . .  517 

Paracentesis  in  ascites         . .          90,  278 

— -  pericarditis            . .           .  .           .  .  389 

Paralyses,  muscular  atrophy  due  to  347 

PARALYSIS  AGITANS                             .  .  385 

—  birth,  of  brachial  plexus.  .           .  .  374 

—  bulbar  (see  Bulbar  Palsy)          .  .  119 

—  diphtheritic           . .           .  .           . .  151 

—  general  (see  Mental  Diseases)   . .  324 

—  infantile  (see  Infantile  Paralysis)  237 

—  from  lead  poisoning        . .          .  .  271 

—  musculospiral,     in     fracture     of 

humerus          . .          . .          . .  183 

—  from  nerve   injuries   (see   Nerve 

Injuries)           .  .           . .           .  .  368 

—  senile  insanity  preceding           .  .  337 

—  following     spinal     injuries     (see 

Spine,  Injiuries  of)     .  .           .  .  48 r 

—  V.  Volkmann's      . .          . .          .  .  347 

Paralytic    obstruction    complicating 

appendicitis    . .          . .          . .  60 

—  phenomena  of  arteriosclerosis  . .  84 

—  talipes        . .          . .          .  .          . .  509 

Paranoia          .  .          .  .           .  .           .  .  318 

—  facial  expression  in         .  .           .  .  301 

Paranoid  dementia    .  .           .  .           .  .  335 

Paraplegia  with  spinal  caries         . .  478 

Parasitic  eczema        . .          . .          . .  162 

Parasyphilitic  portal  cirrhosis        . .  281 

PARATYPHOID  FEVER            .  .            .  .  386 

Parenchymatous  goitre        . .          . .  199 

Parotitis  (see  Mumps)          . .          . .  346 

Paroxysmal    dyspnoea    in    impaired 

contractility  of  ventricles   . .  353 

—  tachycardia  in  myocardial  disease  357 
Patella,  dislocation  of          . .        250,  263 

—  fracture  of  . .  . .  179,  190 
Patellar  ligament,  rupture  of  . .  260 
Patent  foramen  ovale          . .          . .  230 

—  interventricular  septum.  .  . .  230 
Paterson's  operation  for  ascites  .  .  279 
Peliosis  rheumatica  (see  Purpvura)  . .  437 
Pelvic  inflammation,  gonorrhoeal  .  .  204 
Pelvis,  fracture  of    . .          . .        188,  192 

urethral  stricture  in.  .           .  .  525 

Pemphigus  acutus  and  chronicus    .  .  387 

—  contagiosus            .  .           .  .           .  .  386 

— ■  foliaceus     .  .          .  .           .  .           .  .  3S7 

—  neonatorum           .  .           . .           .  .  386 

PEMPHIGUS  AND  PEMPHIGOID  AFFEC- 
TIONS      386 

—  vegetans    . .          . .          . .          . .  387 

PENIS,  CARCINOMA  OF           .  .            •  ■  387 

Perforated  duodenal  ulcer  . .          . .  492 

— ■  gastric  ulcer         . .          . .          . .  489 


PAGE 

508 

4 
522 
342 
401 
388 
120 
133 
392 
450 
389 

391 
107 
521 

54 


204, 
(see  Pneiunococcic 


278 
390 

402 
415 
390 
393 

394 

92 

165 


Perforating  ulcer  of  foot  in  tabes    .  . 

—  wounds  of  abdomen 
Perforation  in  typhoid  fever        519, 

—  of  uterus  from  vesicular  mole  . . 
Pericardial  effusion  with  pleurisv  .  . 
PERICARDITIS 

—  after  burns 

—  chorea  associated  with   .  . 

—  chronic  adhesive  . . 

—  rheumatic,  acute    .  . 

—  tuberculous 

Pericardium,  infusion  into  in  rheu- 
matic infection 

Periosteal  sarcoma     .  . 
Periostitis  in  typhoid  fever. . 
Peritonitis    from    appendicitis    (see 
Appendicitis)  . . 

—  ascites  with 

—  cirrhosis  with 

—  gonococcal 

—  pneumococcic 

Peritonitis) 

—  puerperal  . . 

—  traumatic  . . 
PERITONITIS,  TUBERCULOUS 
ascitic,   ulcerous,   and  fibrous 

types 
cytology  of  ascitic  fluid  in    . . 

—  —  with  enteritis . . 

—  in  typhoid  fever  .  .  .  .         519,   522 
PERNICIOUS  ANEMIA  .  .  .  .      395 

—  —  effect  of  treatment    . .  . .     398 

—  —  history  and  blood  changes  . .     395 

—  —  operations  in  . .  395,  397,  399 

symptoms        . .  . .  . .     397 

Peroneal   muscular    atrophy  .  .      348 

Pertussis  (see  Whooping-cough)      .  .      542 
Perversions  in  puberty  and  adoles- 
cence   . .  . .  . .  . .      334 

Peters'    operation   in    exstrophy   of 

bladder  . .  . .  . .        99 

Petit  mal  (see  Epilepsy)      . .  . .      168 

Pfannenstill's  nascent -iodine  method 

in  larjTigeal  tuberculosis     . .     268 

lupus  vulgaris       . .  .  .      282 

Phalanges,  fractures  of       . .         187,   192 
Phenol  and  sling  method  in  movable 

kidney 
Phenol-sulphone-phthalein     test     in 

nephritis — technique 
Phlebitis  in  typhoid  fever    .  . 
Phlebotomus  fever    . . 
Phlegmonous  gastritis,  diffuse 
Phosphaturia  . . 

Phthalein  test  for  renal  function 
Phthisical  insanity     .  . 
Phthisis    (see    Pulmonarj'   Tubercu 

losis)     .  . 
Phj'siological  albuminuria 
Pigmentation    in    Addison's    disease 

—  diabetes     . . 
Piles  (see  Haemorrhoids) 
Pisiform,  fracture  of 
Pituitary  gland  feeding,  influence  on 

acromegaly,  etc.     .  . 

. operation  in  acromegaly      . .         7 

treatment  in  diabetes  insipidus  144 

PLACENTA  PR.2;VIA  .  .  •  •      399 


345 

367 
520 
517 
486 
144 
367 
338 

418 


209 
186 


S  UPPLEMENTA  R  Y     INDEX 


563 


Plastic  linitis 

Pleural  adhesions,  influence  in  breast 
cancer  . . 

—  effusion,  bronchiectasis  due  to. . 
complicating  appendicitis    . . 

—  —  —  ovarian  tumour,  operation 

curative . . 
Pleuritic  disease,   dangers  of  anaes- 
thetics in 
PLEURITIS 

—  high  tuberculosis  mortality  due  to 

—  importance  of  sanatorium  treat- 

ment   . . 
Plumbic  pseudo-tabes 
Plumbism  (see  Lead  Poisoning) 

—  and  arteriosclerosis 

—  mental  symptoms  of 
Pneumococcal  empyema 

—  meningitis 

—  pericarditis 

—  pleuritis     . . 
PNEUMOCOCCIC  PERITONITIS 
PNEUMONIA 

—  after  burns 

—  complicating   appendicitis 
diphtheria 

typhoid  fever .  . 

—  danger  of,  in  progressive  muscu- 

lar atrophy     . . 

—  in  diabetics 

—  influenzal  . . 

—  after  laryngectomy 

—  myocarditis  with . . 

—  peritonitis  as  sequel 

—  post-operative 

—  unresolved,  bronchiectasis  due  to 
Pneumonic  tuberculosis 
Pneumopericardium  . . 
PNEUMOTHORAX         

—  artificial,  in  pulmonary  tubercu- 

losis 
Podalic  version  in  placenta  praevia 
Poisoning,  acid  (see  Acidosis) 

—  arsenic 

mental  symptoms  of 

—  delayed  chloroform 
following  appendicectomy 

—  by  drug  habits 

—  lead 

—  - —  and  arteriosclerosis    . . 
mental  symptoms  of 

—  mercurial  . . 

—  neuritis  due  to     . . 

—  post-anaesthetic     . . 
Poliomyelitis,  chronic  anterior 

—  and  polio-encephalitis 
Polycystic     kidney     (see      Kidney, 

Polycystic) 

POLYCYTHEMIA  

Polyneuritis    .  . 
Polyorrhymenitis,  ascites  with 
Polypus,  effect  on  asthma  of  removal 
Polyserositis,   pericardial 
Polyuria 

—  in  acute  nephritis 
Popliteal  aneurysm  . . 

—  artery,  haematoma  of 

Portal  cirrhosis  (see  Liver,  Cirrhosis  of) 


PAGE 
498 

Post-ana3sthetic  brachial  paralysis. . 

PAGE 

375 

—  toxaemia    . . 

30 

115 

after  appendicectomy 

63 

117 

Potassium  iodide,  influence  in  actino- 

60 

mycosis 

9 

test  in  nephritis — technique 

368 

90 

Pott's  disease  (see  Spinal  Caries)    . . 

477 

—  fracture      . . 

180 

33 

rareness  of  good  results      175 

,  191 

401 

Pregnancy,     acidosis     in     toxaemic 

402 

vomiting  of    . . 

5 

—  albuminuria  of     . . 

13 

402 

—  with  appendicitis  . . 

67 

271 

—  dermatitis  herpetiformis  in 

387 

270 

—  during  typhoid  fever 

521 

81 

—  ectopic 

160 

340 

—  and  epilepsy 

168 

163 

—  influence  in  chlorosis 

131 

294 

osteomalacia  . . 

380 

389 

—  influenza  during  . . 

240 

401 

—  jaundice  in 

276 

402 

—  malaria  and 

288 

403 

—  mental  diseases  of 

332 

120 

—  with  mitral  stenosis 

224 

60 

—  molar,  effect  on  fertility.  . 

343 

152 

—  ovarian  tumours  and 

383 

520 

—  pernicious  anaemia  due  to 

395 

—  pyelitis  of . . 

439 

348 

—  in  relation  to  diabetes    . . 

149 

149 

—  scarlet  fever  and  . . 

466 

239 

— -  and  small -pox 

473 

266 

—  spinal  caries 

478 

350 

—  typhus   fever 

524- 

402 

—  uterine  fibroids  and 

532 

36 

—  vomiting     of     (see    Vomiting    of 

117 

Pregnancy) 

540 

420 

Pressure  baths  in  emphysema  with 

392 

bronchitis 

118 

406 

effect  on  asthma  . . 

93 

Progressive  muscular  atrophy 

348 

421 

pathological     identity     of 

400 

bulbar  palsy  with 

119 

5 

Prolapsus  recti  (see  Rectal  Prolapse) 

442 

77 

PROSTATE,    CANCER   OF 

408 

340 

PROSTATE,    HYPERTROPHY   OF 

408 

30 

complicating  vesical  calculus 

96 

63 

with  gastric  symptoms 

495 

154 

Prostatectomy  for  cancer     . . 

408 

270 

—  end-results    of    suprapubic    and 

81 

perineal            .  .           .  .         410, 

411 

340 

—  for  hypertrophy  . . 

409 

341 

Prostatic  calciUi 

412 

377 

—  tuberculosis,  relation  to  epididy- 

5, 7 

mitis.. 

166 

348 

with  vesical  tuberculosis 

106 

237 

Prostatitis  complicating  gonorrhoea 

200 

Proteinuria 

13 

254 

Pseudo-angina 

51 

407 

Pseudo-bulbar  paralysis 

119 

377 

PSOAS   ABSCESS           

412 

89 

in  spinal  caries 

479 

93 

PSORIASIS 

414 

392 

Puberty,  influence  on  epilepsy 

168 

144 

—  mental  disturbances  of  . . 

333 

362 

Puerperal  infection,  gonorrhoeal     . . 

215 

45 

—  insanity 

331 

207 

intercurrent  diseases  with    . . 

331 

277 

PUERPERAL   SEPSIS 

415 

36A 


564 


INDEX    OF    PROGNOSIS 


Puerperal  sepsis,  pericarditis  compli- 
cating . . 

Puerperium,  dangers  of  fibroids 
during  . . 

—  pernicious  anemia  beginning  at 
Pugilist's  '  mark,'  shock  from  blow 

on 
Pulmonary  actinomycosis    . . 

—  changes  in  impaired  ventricular 

contractility    . . 

—  complications  of  appendicitis   . . 
measles  . .  . .        289, 

—  embolism  following  operation  for 

varicose  veins 

—  lesions,  dangers  of  anaesthetics  in 

—  oedema  after  ether  inhalation 

—  stenosis,  congenital 

and  regurgitation 

PULMONARY   TUBERCULOSIS 

artificial  pneumothorax  in 

effects  of  climate 

factors  influencing  prognosis 

importance  of  after-conditions 

mental  symptoms  of . . 

—  —  occurrence  with  laryngeal   . . 

—  —  pericarditis  complicating 
peritonitis  with 

pleuritis  a  cause  of  high  mor- 
tality . .  . .        401, 

pneumonic  form 

pneumothorax  curative  in 

relation  of  influenza  to 

with  renal 

results    of    tuberculin    treat- 
ment 

sanatorium  treatment 

Turban's  classification 

Pulse  in  abdominal  contusions 

—  bronchopneumonia 

—  excessive  vomiting  of  pregnancy 

—  head  injuries 

—  importance  as  indication  in  aortic 

regurgitation  . . 

—  indications  in  contractile  failure 
PULSE,   IRREGULARITIES  OF  THE 
absolute  dependence  of  pro- 
gnosis on  diagnosis 

alternating  pulse 

—  —  auricular  flutter 

the  extrasystolic  type 

frequency    in    childhood    and 

youth 

heart-block 

sinus  irregularity 

tachycardia     . . 

total  arrhythmia 

in  myocardial  disease 

PURPURA         

—  haemorrhagica 

—  Henoch's   . . 

—  Schonlein's 

—  simplex 

Pustule,  malignant  (see  Anthrax) 
Pyaemia   complicating   scarlet   fever 

—  pericarditis  complicating 

—  puerperal  . . 
PYELOCYSTITIS 
Pyelolithotomy,  results  of  - . 


390 


533 
395 


355 

59 

290 

539 
33 
36 
230 
229 
418 
421 
422 
420 
421 
338 
268 

389 
394 

402 
420 
406 
239 
255 

428 
423 
424 
I 
119 
540 
211 

225 
354 
430 

431 
435 
432 
430 

430 
434 
430 
431 
432 
357 
436 
436 
437 
437 
436 
51 
467 
389 
415 
437 
261 


PAGE 

Pyelonephritis  (see  Pyelocystitis)   . .     438 

—  complicating  vesical  carcinoma       104 

—  pyonephrosis  secondary  to        . .      441 
Pylephlebitis  complicating  appendi- 
citis     . .  . .  . .  . .  62,  64 

Pyloroplasty  in  congenital  stenosis, 

results  of  . .  . .  440,  496 
Pylorus,  congenital  hypertrophy  of  487 
PYLORUS,  CONGENITAL  STENOSIS  OF  439 
medical  treatment  439,  496 

—  —  —  surgical  treatment         440,  496 


PYONEPHROSIS             

•     441 

—  with  hydronephrosis 

•     233 

Pyopericardium 

•     391 

Pyorrhoea     alveolaris,     relation     to 

rheumatoid  arthritis. . 

•     456 

Pyosalpinx 

•     464 

Pyrexia  of  lymphadenoma  . . 

.     287 

—  measles 

.     290 

QUININE,  abortion  due  to         . .  288 

"D  ADIUM  in  cancer  of  rectum    . .  445 
tongue 514 

—  —  uterus  . .          . .          . .          . .  529 

vulva    . .          . .          . .          . .  542 

—  fibroids  of  uterus  . .          . .          . .  534 

—  lichen  planus        . .          . .          . .  274 

—  ovarian  tumours  . .          . .          . .  383 

—  papilloma  of  larynx        . .          . .  267 

—  recurrent  cancer  of  breast       113,  115 

—  rodent  ulcer          . .          . .          . .  462 

—  sarcoma  of  bone  . .          .  -          . .  109 

—  water  in  rheumatoid  arthritis  . .  459 
Radius,  myeloid  sarcoma  of           . .  107 

—  fracture  of  . .  .  .  185,  191 
Railway  spine  . .  .  .  ■ .  480 
Reactions,  electrical,  in  local  neuritis  378 

RECTAL  PROLAPSE 442 

RECTUM,  CANCER  OF      .  .     .  ■  442 

mortality  of  various  operations  443 

radium  in        . .          . .          . .  445 

recurrence  after  operation  . .  444 

Reciirrent  laryngeal  nerve,  injuries 

to          374 

Reflexes  in  tabes  dorsalis    . .          . .  506 

Refraction,  errors  of,  with  migraine  141 

Refracture  of  patella            . .          . .  180 

Regurgitation,  aortic            . .          . .  224 

—  mitral         . .          . .          ■ .          •  •  218 

—  pulmonary             . .          . .          •  •  229 

RELAPSING   FEVER 447 

influence  on  lymphadenoma  287 

Renal  artery,  aneurysm  of  . .          . .  38 

—  colic  with  appendicitis   . .          . .  65 

—  contusions,  etc.  (see  Kidney) 

Rest  treatment  in  Addison's  disease  9 

Retinitis  of  chronic  nephritis         . .  366 

Retinitis  in  lead  poisoning  . .          . .  271 

—  prognostic  value  in  gout  . .  206 
Rheumatic  carditis,  dilatation  in  . .  356 
relation  to  pericarditis         . .  388 

—  facial    palsy,    muscular    atrophy 

from     .  .          . .          • .          •  •  347 

RHEUMATIC  FEVER 447 

Are  the  salicylates  specific  ?  448 

—  gout            459 


SUPPLEMENTARY    INDEX 


565 


Rheumatic   infection,    effusion   into 

pericardium  in           . .          . .  391 

—  origin  of  valvular  disease          .  .  218 
RHEUMATIC  PERI-,  MYO-,  AND  ENDO- 
CARDITIS (acute)         .  .           .  .  450 

Rheumatism,    acute,    mental    sym- 
ptoms in         . .          . .          . .  339 

—  all  cases  of  chorea  to  be  looked 

upon  as  due  to         ..          ._.  133 

—  chronic  pericardial   adhesions  in  392 

—  the  liability  to  recurrence  in     . .  133 

—  post -scarlatinal     .  .          .  .           .  .  467 

EHEUMATOID  ARTHRITIS     .  .            .  .  455 

influence  of  treatment          . .  459 

predisposing  causes   . .          . .  456 

—  —  rheumatic  form  of      .  .          .  .  448 

Still's   disease..          ..          ..  458 

Rib,  cervical  (see  Cervical  Rib)       .  .  128 

nerve  injury  due  to  . .          . .  375 

Ribs,  fracture  of       ..           ..         188,  192 

Richter's  hernia         .  .          .  .          .  .  217 

RICKETS            461 

—  genu  valgum  with           . .          . .  198 

—  influence   on   bronchopneumonia  118 

—  and  splenic  anaemia  of  infancy  18 

—  whooping-cough  with  . .  . .  543 
Rigors  in  typhoid  fever  . .  . .  519 
RINGWORM 461 

—  fungi  causing  '  eczema  ' . .  . .  162 
Robertson    (Ford)    or    causation    of 

general  paralysis        . .          . .  324 

RODENT  ULCER  .  .  • .  •  •  462 
Rogers's     hypertonic     solution     in 

bacillary  dysentery   .  .           . .  138 

Routte's  operation  for  ascites         . .  279 

RUBELLA          463 

Rupture  of  bladder    . .          . .          . .  3 

—  intestine     .  .           .  .          •  .           ■  •  2 

—  kidney        . .          . .          - .          •  •  3 

—  liver           . .          . .          . .          . .  2 

—  ovarian  cyst          . .          . .          . .  382 

—  pancreas    . .          . .          . .          _.  .  3 

—  spleen,  from  abdominal  contusion  i,  3 

—  urethra       .  .           . .          . .           •  •  525 

—  uterus  (see  Uterus,  Rupture  of)  535 
from  vesicular  mole  . .          . .  342 

CACRO-ILIAC  disease,    tuberculous    88 

^     Sacrum,   fracture  of      .  .           .  .  192 

Salicylate      treatment     in     mental 
symptoms  of  rheumatism  and 

chorea  . .          . .           . .          . .  339 

Salicylates  in  rheumatic  carditis    . .  455 

—  in  rheumatic  fever  .  .  .  .  448 
Salicylic     acid    in     prophylaxis    of 

tetanus            . .          . .          . .  512 

Salpingectomy,  results  of     . .          .  .  464 

SALPINGITIS                   463 

—  gonorrhoeal            .  .           . .           .  .  204 

—  tuberculous  .  .  .  .  ■  .  465 
Salpingo-oophoritis  .\  . .  .  .  463 
Salt-free  diet  to  avert  eclampsia     .  .  14 

in  diabetes  insipidus.  .           .  .  144 

influence  on  ascites  . .           . .  90 

Salvarsan     treatment      of     cardiac 

syphilis         .  .          .  .           .  .  123 

lymphadenoma           . .          . .  286 

pernicious  anaemia     . .          . .  398 


PAGE 

Salvarsan    treatment     of    relapsing 

fever . .          . .          . .          . .  447 

—  —  syphilis             . '.           . .           .  .  503 

—  —  syphilitic  mental  disease  .  .  325 
Sanatorium    treatment,    importance 

in  pleuritis  .  .          . .           .  .  402 

in  laryngeal  tuberculosis      .  .  268 

recurrent  cancer        . .          . .  114 

—  — -  results  in  phthisis  . .  ■  .  423 
Sanitation  and  rheumatic  fever  .  .  449 
Sarcoma,  cerebral      . .          . .          . .  128 

—  of  jaw        .  .           .  .           . .          . .  247 

—  kidney        . .           . .           . .          . .  251 

SARCOMA,  MELANOTIC           .  .            .  •  291 

—  —  principles    and    prospects    of 

operation     . .          . .          . .  292 

supervening  on  a  mole         . .  342 

—  of  spine     . .           . .          . .           . .  484 

—  stomach     .  .          .  .           .  .          . .  498 

—  testis          . .          . .          . .          . .  510 

—  tongue        . .          . .          . .          . .  517 

—  transformation  of  lymphadenoma 

into       . .          . .          . .          . .  286 

Sarcomata,  myeloid  and  periosteal  . .  107 
Sarcomatous  degeneration  of  uterine 

fibroids             .  .          . .           .  .  531 

Scalds  (see  Burns  and  Scalds)        . .  120 

Scalp,  cellulitis  of      . .          . .          . .  124 

Scaphoid,   carpal,    fracture   of         .  .  186 

—  tarsal,  fracture  of  ..  ..  182 
Scapula,  fracture  of  . .          . .          . .  187 

—  sarcoma  of            . .           . .           .  .  108 

SCARLET  FEVER          465 

acute  nephritis  of      .  .          . .  363 

—  — ■  complications              . .          .  .  466 

myocarditis  with       . .          . .  350 

pericarditis  of             .  .           . .  390 

symptoms  of  special  serious- 
ness . .          . .          . .          . .  466 

Schauta's    operation    in    cancer    of 

uterus  . .          . .       _  . .         _. .  528 

Schede's  operation  for  varicose  veins  539 

Schonlein's  purpura  . .          . .          . .  437 

School  certificates,  pulse  irregularity 

and       . .          . .          . .          . .  430 

—  teachers,  severity  of  rheumatoid 

arthritis  in      . .          . .          . .  457 

SCLATICA           467 

Scirrhus  of  breast  (see  Breast)       .  .  no 

Sclavo's  serum  in  anthrax  . .          . .  51 

Sclerosis,  disseminated         .  .           .  .  153 

SCOLIOSIS 468 

Scopolamine  with  general  anaesthesia  24 
Scopolamine-morphia,    influence    on 

surgical  shock  . .  .  •  34 
Scottish  Board  of  Lunacy,   Reports 

of          298 

SCROTUM,  CARCINOMA  OF  .  .           •  •  469 

SCURVY             469 

Seborrhoeic  eczema    . .          . .          . .  162 

Secondary    anaemia    (see    Anaemia, 

Secondary)       . .          .  .          .  -  15 

Semilunar  bone,  fracture  of . .          . .  186 

—  cartilage,  injuries  to  .  .  . .  263 
Seminal    vesicles,     tuberculosis    of, 

with  vesical  tuberculosis      .  .  106 

—  vesiculitis  complicating  gonorrhoea  201 
Senile  gangrene          . .          . .          . .  197 


566 


INDEX    OF    PROGNOSIS 


Senility,  eczema  of    . . 

—  and  melancholia  . . 
- —  mental  disturbances  of  . . 

—  myocardial  degeneration  in 

—  premature,  from  alcoholism 
Sepsis  in  burns  and  scalds  . . 

—  cancer  of  bladder 

—  vesical  calculus    . . 
Septic  complications  in  head  injuries 

—  conditions,  anaesthetics  in 
SEPTICEMIA  .  .  ■  • 

—  pericarditis   complicating 

—  puerperal   (see   Puerperal  Sepsis) 
Serum  therapy  in  bacillary  dysentery 

bronchopneumonia    . . 

and  diphtheritic  heart  failure 

in  exophthalmic  goitre 

gonococcal  meningitis 

meningococcal  meningitis 

pernicious  anaemia     .  . 

—  —  puerperal  sepsis 
septicaemia 

—  —  tetanus 

typhoid  fever .  . 

ulcerative   endocarditis 

Sesamoid  bones  of  thumb,  fracture  of 
Sexual  power  after  epididymectomy 

prostatectomy  410,  411 

Sheep's  brain  emulsion  in  tetanus  .  . 
Shock  in  abdominal  contusions 

—  from  fear  in  anaesthesia  .  . 

—  relation  of  anaesthetics  to 

—  in  ruptured  kidney,  significance  of 
Shoulder,  adhesions  following  sprain 

—  dislocation  of 

—  tuberculosis  of     .  . 

Silver  salts,  influence  in  gonorrhoe 
Sinus  arrhythmia 

—  thrombosis,  lateral 

Sinusitis,  nasal  accessory  (see  Nasal 

Accessory  Sinusitis)  . . 
Skin,  actinomycosis  of 
- —  affections  in  diabetes 

—  antecedent  conditions  predispos 

ing  to  eczema 

—  symptoms  in  melancholia 
Skull,  injuries  of  (see  Head  Injuries 

—  sarcoma  of 
Sleep  in  relation  to  mental  disease 
Sleeping    sickness    (see    Trypanoso 

miasis) . . 
Sleeplessness  (see  Insomnia) 
SMALL-POX 

—  age  incidence 

—  complications 

—  influence  of  race  in 

—  sex  incidence 

—  special  symptoms 

—  vaccination  and  . . 
Sodium    bicarbonate,    influence    on 

acidosis 
Solar  plexus,  death  from  blow  over 
Soubottine's'  operation  in  exstrophy 

of  bladder 
Spa     treatment      of      rheumatoid 

arthritis 
Speech,  effects  of  chronic  alcoholism 


PAGE 

162 

309 

335 
351 
327 
120 
104 
96 
211 

33 
469 

389 
415 
139 
119 

349 
171 
295 
294 
398 
417 
470 
512 
522 
165 
187 
167 
412 

513 

I 

21 

33 

3 

250 

250 

88 

200 

430 

244 

361 
9 


162 
308 
210 
108 
302 

517 

470 
470 
473 
472 
471 
472 
474 


100 
459 
327 


PAGE 

Speech,  effects  of  laryngectomy  on . .  266 

—  results  in  cleft-palate  operations 

136,  137 

Sphenoidal  sinusitis  . .          . .          . .  362 

SPINA  BIFIDA               475 

Morton's  fluid  and  operation 

in          . .          . .          . .          . .  476 

Spinal  analgesia,  after-effects         . .  36 

contra-indications      . .          . .  27 

death-rate  under       . .          . .  26 

—  —  methods  of      . .          .  .          . .  29 

relative  safety  of       .  .          . .  25 

SPINAL  CARIES           477 

—  —  abscess  from  . .          . .          . .  412 

—  cord,  haemorrhage  into   . .           .  .  481 

—  curvature  (see  Scoliosis)  . .  468 
Spine,  fractures  of    . .          .  .          .  .  480 

—  hydatid  cysts  of  .  .          . .          .  .  no 

SPINE,   INJURIES  OF 479 

gun-shot  wounds  of  cord     . .  483 

value  of  laminectomy          . .  482 

SPINE,  TUMOURS  OF  .  .  .  .  484 
results  of  operation  . .          . .  485 

—  typhoid      .  .          .  .           .  .           ■  .  521 

Spirochaetosis .  .           . .          .  .           .  .  447 

Spleen  enlargement  in  leukaemia  272,  273 

—  gunshot  wounds  of         . .           . .  4 

—  ruptured,  from  abdominal  contu- 

sion      . .  . .  . .  . .    I,   3 

Splenectomy  in  cirrhosis  of  liver    .  .  279 

—  contra-indicated  in  leukaemia   . .  274 

—  in  splenic  anaemia           . .          . .  17 

of  infancy  contra-indicated  19 

SPLENIC  ANEMIA 16 

ascites  due  to            . .          . .  89 

Splenomedullary  leukaemia . .  . .  271 
Splenomegalic     polycythaemia     (see 

Polycythaemia)            . .          . .  407 
Splenomegaly,     Egyptian,     hepatic 

cirrhosis  with..          ..          ..  279 

—  infantile     . .          . .          .  ■          . .  517 

—  primary  (see  Anaemia,  Splenic)  16 
Splint      compression,       Volkmann's 

paralysis  from           . .          .  •  347 

Sprain-fracture           .  .          .  •          . .  249 

Sprains              . .          .  •          .  •          •  •  249 

—  arthritis  and  adhesions  following  250 
Sprue    . .          . .          . .          •  •          . •  138 

Stanhope   Sanatorium,   statistics   of 

treatment  at  . .          . .          • .  425 
Staphylococcal    infections,    pericar- 
ditis with        . .          . .          . .  390 

—  meningitis  . .  • .  .  •  295 
Starvation,  the  acidosis  of  . .  . .  5,  6 
Stasis,  pitch  of,  in  mitral  stenosis  . .  222 
Status     lymphaticus,     relation     of 

anesthetics  to 

and  spinal  analgesia . . 

Steinmann's  method  in  fractures 
Stenosis,  aortic 

—  mitral 

—  pulmonary,   acquired 
congenital 

—  of  pylorus,  congenital 

—  tricuspid    .  . 
Sternum,  fracture  of 
Sterility,  gonorrhoea  and 

—  vesicular  mole  and 


29 

27 

174 

227 

220 

229 

230 

496 

. .  229 

187,  192 

202 

••   343 


439, 


SUPPLEMENTARY    INDEX 


567 


of 


486, 


Stigmata  of  degeneration  in  mental 
disease 

—  —  with  mental  heredity 

in  secondary  dementia 

Still's  disease 

Stimulants  in   pneumonia,   need 

pushing 
Stokes-Adams  syndrome 
Stomach,  carcinoma  of 
relation  to  ulcer 

—  cirrhosis  of 

—  dilatation  of 

—  gunshot  wounds  of 

—  hour-glass  .  . 
STOMACH,  MEDICAL  AFFECTIONS  OF 

—  sarcoma  of 

STOMACH,  SURGICAL  AFFECTIONS  OP 

—  syphilis  of 

STOMATITIS  (simple,  aphthous,  mer- 
curial,  ulcerative) 

Stovaine  in  local  analgesia  . . 

Strain,  emotional  and  physical,  in 
causation  of  myocardial 
degeneration    .  . 

Streptococcal  empyema 

—  infections,     pericarditis    as    ter- 

minal phase  of 

—  meningitis . . 

—  pleuritis 

Streptothricosis,  relation   to  actino- 
mycosis 
Stricture  of  oesophagus 

—  urethral      .  .  . .  .  .         525, 

STROKES  

—  mental  symptoms   with .  . 
Strychnine  in  chronic  anterior  polio- 
myelitis 

—  doubtful    benefit    with    general 

ansesthesia 

—  in  retarding  bulbar  palsy 
Stupor  in  dementia  prsecox . . 

—  mental  (see  Mental  Diseases)  .  . 
Stuporose   symptoms   in   adolescent 

insanity 
Subclavian  aneurysm 
SUBPHRENIC  ABSCESS 

complicating  appendicitis     .  . 

Suicidal   impulse  at    the  climacteric 

in  lactational  insanity 

melancholia     . .  . .        309, 

puerperal  insanity 

Suicide,  uncontrollable  impulse  to .  . 
Sulphate  of  magnesium  in  tetanus. . 
Sulphonal  poisoning. . 
Summer  diarrhcea  of  infancy 
Suprarenal     extract     in     excessive 

vomiting  of  pregnancy       540, 
Suture  of  nerves 

—  operations  in  movable  kidney  . . 
Syme's  operation  in  cancer  of  tongue 
Sympathectomy     in     exophthalmic 

goitre    . . 
Syncope,     rareness     in     myocardial 

disease 
Synovial  fringes,  hypertrophied 
Synovitis  of  knee-joint 

—  syphilitic   . . 


PAGE 

304 
340 
322 


406 
434 
496 
489 
498 
484 


491,  496 


487 

499 
25 


351 
163 

390 
295 
401 


379 

526 

500 
500 

348 

25 
119 
335 

321 

334 
46 
502 
58 
336 
332 
312 

331 
320 

513 
155 
150 

541 
369 

345 
514 

171 

354 
263 
262 
506 


PAGE 

SYPHILIS     503 

—  acute  yellow  atrophy  of  liver 

due  to. .     . .    . .    . .  276 

—  and  aortic  regurgitation. .          . .  224 
SYPHILIS,   CARDLA.C 122 

—  cerebrospinal,  disseminated  scler- 

osis simulating          . .          . .  153 

—  congenital. .          . .          . .          . .  505 

—  cure  in  primary  stage     .  .          . .  503 

—  early  cure  of,  to  prevent  general 

paralysis          .  .          . .          . .  325 

—  of  liver,  ascites  of           . .          . .  89 

—  myocardial  degeneration  in       . .  351 

—  as  predisposing  cause  of  general 

paralysis          . .           .  .          .  .  324 

—  relation  to  Addison's  disease     . .  9 

angina  pectoris  . .  47,  50 

aphasia  of  thrombotic  origin  53 

—  —  arteriosclerosis            .  .           .  .  81 
dilatation  of  aorta     . .          . .  53 

—  of  the  stomach     . .          .  .          . .  487 

—  tertiary  symptoms          .  .           .  .  505 

—  tuberculosis  with.  .          .  .           .  .  420 

—  value  of  salvarsan,  mercmry,  and 

iodides  compared       .  .          . .  503 

—  and  valvular  disease       .  .           . .  218 
Syphilitic  bulbar  palsy         . .          . .  119 

—  cirrhosis  of  liver  .  .           .  .          . .  280 

SYPHILITIC  JOINTS                   .  .            .  .  506 

—  mental  ssrmptoms  . .          . .          . .  325 

Syphiloma,  cerebral  . .          . .          . .  125 

'TTABES,       disseminated     sclerosis 

-•■       mistaken  for       .  .           .  .           .  .  153 

TABES  DORSALIS  (see  also  Ataxias,  93)  506 


Tabetic  arthropathies 

—  ataxia 
Tachycardia  (see  Pulse,  Irregularities 

of) 

—  paroxysmal,  in  myocardial  disease  357 

—  progressive,  in  contractile  failure     355 

TALIPES  

Talma-Morison  operation  for  ascites 
Tarsal  scaphoid,  fracture  of . . 
Tarsus,    fractures    involving         182, 
Tar -workers'  cancer  . . 
Taxis  in  strangulated  hernia 
Teeth,  carious,  removal  with  opera- 
tion   for    tuberculous    glands 

—  relation  to  rheumatoid  arthritis 
'  Teething  convulsions  ' 
Temperament,     effect     on     arterio- 
sclerosis 

—  in  myocardial  disease 
Temperature  in  head  injuries 

—  hemiplegia 

—  high,  in  children,  mental  disturb- 

ance with        .  .  . .  . .      333 

—  importance  in  puerperal  insanity     331 

—  in  measles. .  . .  . .  . .     290 

—  relation  of  anaesthetics  to  .  .        33 

—  in  typhus  fever    .  .  .  .  .  .      524 

Temporosphenoidal  abscess  . .     244 

TENOSYNOVITIS  509 

Testes,  results  of  mumps  on  .  .      346 

TESTIS,   NEW  GROWTHS   OF  ..      510 

—  tuberculous  (see  Epididymitis)         166 
Tests  for  acidosis      . .  . .  . .         5 


508 
93.  506 


431 


509 
278 
182 
191 
469 
215 

285 
456 
236 

83 
352 
211 
501 


568                                        INDEX 

OF 

PROGNOSIS 

PAGE 

PAGa 

TETANUS          

511 

Transport,   influence   on   abdominal 

—  after  burns 

121 

wounds 

4 

Tetronal  poisoning    . . 

155 

Trapezium  and  trapezoid,  fracture  of 

186 

Thoracentesis,  pneumothorax  due  to 

406 

Traumatic  epilepsy   . . 

212 

Thoracic  aneurysm  (see  Aneurysm, 

Trendelenburg's  operation  for  vari- 

Intrathoracic) 

39 

cose  veins 

539 

—  duct,  wounds  of     . . 

513 

Tricuspid  valve,  congenital  atresia  of 

230 

Thoracostomy    in    chronic    adhesive 

—  valve,  lesions  of 

228 

pericarditis 

392 

Trigeminal  neuralgia  (see  Neuralgia, 

Throat  affections  with  measles 

290 

Trigeminal)      .  . 

37& 

Thrombophlebitis,  puerperal  415,  417 

,418 

Trional  poisoning 

155 

Thrombosis,    cerebral    (see   Strokes) 

500 

Tropacocaine  in  local  analgesia 

25 

—  —  relation  to  aphasia    . . 

53 

TROPICAL  FEVERS 

517 

—  complicating    appendicitis 

59 

TRYPANOSOMIASIS 

517 

—  lateral  sinus 

244 

Tubal  disease  (see  Salpingitis) 

463 

—  venous,  complicating  chlorosis . . 

132 

—  gestation  (see  Ectopic  Pregnancy) 

160 

in  typhoid  fever 

520 

Tubercle  bacilli,  influence  on  brain 

Thrush             

499 

disease 

338 

Thymus,  enlarged,  with  exophthal- 

Tuberculin in  renal  tuberculosis      .  . 

256 

mic  goitre 

172 

—  Addison's  disease 

10 

Thyro-fissure  in  papilloma  of  larynx 

267 

—  epididymitis 

167 

—  results  in  laryngeal  carcinoma  .  . 

265 

—  lupus  vulgaris 

284 

Thyroid,  ansesthesia  in  operations  on 

32 

—  lymphadenitis 

284 

—  cancer 

109 

—  pulmonary  tuberculosis 

428 

—  extract  in  excessive  vomiting  of 

—  vesical   tuberculosis 

io5 

pregnancy        . .          . .         540, 

541 

Tuberculoma,  cerebral 

125 

—  gland  administration  in  cretinism 

324 

Tuberculosis,     acute,     complicating 

affections      with      congenital 

measles 

290 

amentia 

324 

—  of  bladder  (see  Bladder,  Tuber- 

— operations  in  exophthalmic  goitre 

172 

culosis  of) 

105 

—  treatment  and  mental  symptoms 

—  breast 

116 

of  myxoedema 

339 

—  cfficum 

121 

Th5T:oidectomy  for  goitre     . . 

199 

—  with  diabetes 

149 

Tibia,  fracture  of      . .          . .        180, 

190 

—  effusion  into  pericardium  in     . . 

391 

—  sarcoma  of            . .          . .        107, 

108 

—  of  kidney  . . 

254 

Tic     douloureux      (see     Neuralgia, 

—  larynx  (see  Larynx) 

268 

Trigeminal) 

376 

—  miliary,  caseous,  and  pneumonic 

420 

Tick  fever  (see  Relapsing  Fever)     .  . 

447 

— pulmonary  (see  Pulmonary  Tuber- 

Tobacco in  etiology  of  arteriosclerosis 

81 

culosis) 

418 

Tongue,  actinomycosis  of    . . 

8 

after    lymphadenitis            284, 

285 

TONGUE,  CANCER  OF 

513 

relation  of  influenza  to 

239 

mortality  of  operation 

514 

—  and  scarlet  fever.  . 

467 

prognosis  apart  from  operation  513 

—  following  spinal  injuries 

479 

prospects  of  cure 

515 

—  syphilis  with 

505 

time  and  situation  of  recurrence  516 

Tuberculous     abscess     from     spinal 

—  papilloma  of 

517 

caries    . . 

412 

—  sarcoma  of 

517 

—  arthritis  (see  Arthritis)     . . 

85 

Tonsillectomy    with    operation    for 

—  empyema  . . 

163 

tuberculous  glands    . . 

285 

—  enteritis 

165 

Tonsillitis  with  rheumatic  fever 

449 

—  epididymitis  (see  Epidymitis)   . . 

166 

Tooth's  peroneal  muscular  atrophy 

348 

—  glands     mistaken     for     lympha- 

—  report  on  cerebral  tumour 

125 

denoma 

286 

Toxaemia,  post-operative      . . 

30 

—  lymphadenitis  (see  Lymphadenitis 

284 

after  appendicectomy 

63 

—  meningitis . . 

295 

Toxaemias  of  pregnancy 

332 

movements     in,     simulating 

—  and  rheumatoid  arthritis 

455 

chorea 

134 

Toxaemic      jaundice      complicating 

—  peritonitis  (see  Peritonitis,  Tuber- 

appendicitis    . . 

62 

culous) 

393 

—  vomiting  of  pregnancy  . . 

540 

Asiatic  form  of 

89 

Toxic  angina  . . 

51 

cytology  of  ascitic  fluid     in 

92 

Toxins  causing  arteriosclerosis 

81 

—  pleuritis     . . 

401 

Tracheotomy     or     intubation     in 

—  salpingitis 

465 

diphtheria 

152 

—  tenosynovitis 

510 

—  in  laryngeal  tuberculosis 

269 

Tufnell's    treatment    in    abdominal 

—  papilloma  of  larynx 

267 

aneurysm     .  . 

39 

Trance  in  adolescent  insanity 

334 

intrathoracic  aneurysm 

42 

Transfusion   of  blood  in  pernicious 

Tumours   of  bladder    (see    Bladder, 

anaemia 

399 

Growths  of)     . . 

100 

S  UPPLEMENTA  R  Y    INDEX 


569 


PAGE 

Tumours  of  bone      . .          . .          . .  106 

—  brain,  ataxia  due  to        . .          . .  94 

—  —  disseminated     sclerosis     mis- 

taken for     . .          . .           . .  153 

—  —  mental  symptoms  with         .  .  328 

—  cerebral      . .  .  .  . .         124,   125 

—  —  relation  to  aphasia   .  .           . .  53 

—  complicating  vesical  calculus    . .  96 

—  of  jaw,  lower       . .          . .          . .  249 

upper    . .          . .          . .          . .  247 

—  kidney        . .          .  .          . .          . .  251 

—  larynx,  malignant           . .          . .  265 
papillomatous              .  .          . .  267 

—  malignant,  hydronephrosis  due  to  233 

—  ovarian    (see    Ovarian   Tumours)  381 

—  of  spine  (see  Spine,  Tumours  of)  484 
Turban's  classification  of  pulmonary 

tuberculosis     .  .          . .           .  .  424 

Tympanites  with  ascites  of  cirrhosis  278 

TYPHOID    FEVER         518 

age,  sex,  and  character  of  the 

attack          . .          . .          . .  518 

—  —  cardiac  complications  in      .  .  350 

-in  etiology  of  arteriosclerosis  81 

haemorrhage  in           .  .           .  .  520 

perforation      . .          . .        519,  522 

■  pericarditis  complicating     . .  390 

peritonitis  in  . .          . .          . .  519 

pregnancy  during      . .          . .  521 

prophylactic  inoculation      . .  523 

—  —  surgical  treatment     . .          . .  522 

symptoms  and  complications  519 

treatment         .  .          .  .          .  .  521 

—  form  of  scarlet  fever      . .          . .  466 

—  spine          . .          . .          . .          . .  521 

Typhoidal  meningitis           . .          . .  295 

TjTJho-mania  (see  Mental  Diseases)  314 

TYPHUS  FEVER           523 

age  incidence..           ..           ..  523 

—  —  sex,  complications,  and  special 

symptoms    . .          . .          . .  524 


156,  492 

..  487 

75 


502 
493 
508 

173 
138 


T  T  LCER,  duodenal . . 
^      —  gastric 

with  chronic  appendicitis     . . 

operative   treatment 

and      duodenal,      subphrenic 

abscess  due  to 

—  jejunal,   after  gastrojejunostomy 

—  perforating,  of  foot,  in  tabes     . . 
Ulceration  of  cornea  in  exophthal- 
mic goitre 

Ulcerative  colitis 

—  endocarditis    (see    Endocarditis, 

Ulcerative)      . .  . .  . .      164 

—  stomatitis  . .  . .  . .  . .     499 

Ulna,   fracture  of      . .  . .         185,  191 

—  myeloid  sarcoma  of        . .  . .      107 

Ulnar  nerve,  injury  to         . .  . .     375 

Umbilical  hernia        .  .  . .  . .      214 

Unciform  bone,  fracture  of . .  . .      186 

Unconsciousness  (see  Coma) 

UR.21MIA  .  .  .  .  .  .  .  .      524 

—  of  acute  nephritis  . .  . .     363 

—  from  renal  calculus         . .        258,  261 
Urea     excretion,      defective,      pre- 
eclamptic    . .  . .  . .        14 

relation  to  acidosis    . .  . .         6 


Ureter,  calculus  of  (see  Kidney)    . . 

—  operations  on  in  hydronephrosis 
URETHRA,   RUPTURED 
URETHRAL  STRICTURE 
Urethritis,  gonorrhceal  .  .         200, 
Urethrotomy  in  stricture 

Urinary  complications  of  tabes  dor- 
salis 

—  obstruction    with    gastric    sym- 

ptoms . . 

—  system  function  in  eclampsia  . . 
Urine,  albumin  in  (see  Albuminuria, 

Nephritis) 

—  daily    output    of,    in    impaired 

ventricular  contractility 

—  deviation  of  course  in  exstrophy 

of  bladder 

—  diazo-reaction   of,   in  pulmonary 

tuberculosis     . . 

—  examination  in  diabetes. . 

—  —  excessive    vomiting   of   preg- 

nancy 

—  —  nephritis  . .  . .         362, 

post-operative  toxaemia 

pregnancy 

—  extravasation  of  . .  .  .         525, 

—  iodide  of  potash  test,  technique 

—  normal,  albumin  in 

—  phthalein  test,    technique 

—  tests  for  acidosis  .  . 
Uropyonephrosis  (see  Pyonephrosis) 
Uterine  tumours,  ascites  due  to      8g 
Uterus,    affections    connected    with 

salpingitis 
UTERUS,   CANCER  OF 

of  the  body    . . 

of  the  cervix 

iibryoma  as  predisposing  cause 

of 

—  —  results  of  treatment 

—  chorion-epithelioma  of    .  . 
UTERUS,   FIBROIDS  OF 
with  cancer     . . 

degenerative  changes  in 

—  —  operative  treatment 

palliative       and       expectant 

treatment    . . 
risks  in  presence  of    . . 

—  gonorrhceal  infection  of  . . 

—  perforation  or  rupture  of,   with 

vesicular  mole 

—  results  of  operative  treatment  . . 
UTERUS,   RUPTURE   OF 


PAGE 
258 
235 
525 

203 
526 

507 

495 
159 


354 
99 

422 
147 

540 

367 

31 

14 

526 

368 

II 

367 

5 

441 

-  90 

464 
526 
529 

526 

532 
528 
135 
530 
530 
531 
533 

535 
531 
204 

342 
537 
535 


Y'ACCINATION,  antityphoid  ..  523 

—  and  small-pox           . .  . .  470 

Vaccine  therapy,  in  bronchitis  . .  118 

effect  on  asthma  . .  . .  93 

gonorrhoea       . .  . .    201,  202-5 

—  —  nasal  accessory  sinusitis  . .  359 

puerperal  sepsis          . .  . .  417 

rheumatoid  arthritis  . .  459 

typhoid  fever..          ..  ..  522 

—  —  ulcerative  endocarditis  . .  165 

vesical  tuberculosis  . .  . .  106 

Vaginitis,  gonorrhceal  . .  . .  202 
Valvular  disease  (see  Heart)  . .  217 
with  angina  pectoris  . .  48 


570 


INDEX     OF     PROGNOSIS 


Valvular  disease,  relation  to  primary- 
disease  of  myocardium 
Varicella  (see  Chicken-pox 


349 

129 


—  bullosa,  gangrenosa,  and  hamor 

rhagica  (see  Chicken-pox) 
VARICOCELE    .  . 

—  with  renal  growths 
VARICOSE   VEINS 

eczema  with  . . 

Variola  (see  Small-pox) 

Varix,   aneurysmal     . . 

Vasectomy  in  hypertrophy  of  prostate  409 

Vasodilators  in  high  arterial  tension       80 

—  significance   of  effect   in   angina 

pectoris 
Veins,  varicose  (see  Varicose  Veins) 
Vejlefjord  Sanatorium,   statistics  of 

treatment  at  . . 
Vena  cava  inferior,  wounds  of 
Venesection   in   aortic  regurgitation 
Venous     thrombosis,      complicating 
chlorosis 

gouty    . . 

Ventricles,    condition   of,   in   mitral 

stenosis 

—  impaired  contractilit}^  of 

importance  of  symptoms  in  353 

Version,  podalic,  in.  placenta  praevia     400 
Vesical  rupture,   etc.   (see  Bladder) 

—  moles   (see   INIoles) 
chorion-epithelioma  following 

135 
Venous  thrombosis  in  typhoid  fever 
Visceral  crises  of  tabes 
Visual  phenomena  of  migraine 
Vitry-Sezary  operation  for  ascites  .  . 
Volkmarm's  paralysis  . . 
Volvulus,  obstruction  due  to 

—  results  of  operation  for  .  . 
Vomiting  in  abdominal  contusions . . 

—  in  exophthalmic  goitre  .  . 

—  intestinal  obstruction 

—  measles 

—  with  movable  kidney 

—  in  myocardial  disease 

—  with  post-haemorrhagic  anaemia 

—  post -operative 
VOMITING  OF  PREGNANCY  .  . 

toxaemic,  acidosis  in .  . 

Von  Eiselsberg's  report  on  cerebral 

tumour 
VULVA,  CARCINOMA  OF 
Vulvovaginitis,  gonorrhoeal. . 


129 
538 
254 
539 
162 
470 
47 


49 
539 

423 
238 
224 

132 
206 

223 
353 


342 

342 
520 
508 
141 
279 
347 
241 
242 
I 

..      174 

240,  243 

290 

•  •      344 

354 

15 

34 

540 

5 

125 

541 
202 


W7ASSERMANN     reaction      (see 
*  ^      Syphilis) 

of  ascitic  iluid 

in  general  paralysis  . . 

syphilitic  mental  disease 

tuberculosis     .  . 

Wasting  in  exophthalmic  goitre 


504 
92 
324 
325 
420 
174 


Water  injection  in  intussusception  245 
Wertheim's  hysterectomy  in  cancer 

of  cervix          . .          . .          . .  52S 

Whitehead's  operation  in  cancer  of 

tongue..          ..          ..          ..  514 

Whitman's  operation  in  coxa  vara. .  143 

WHOOPING-COUGH 542 

—  bronchiectasis  as  a  sequel         . .  116 

—  bronchopneumonia   with            .  .  118 
Widal  reaction           . .          . .          . .  519 

Wiring  of  sac  in  abdominal  aneurysm  3S 

intrathoracic  aneurysm        . .  43 

Woolsorters'  disease..          ..          ..  51 

Workmen's  compensation,  fractures 

in  relation  to  . .          . .          . .  188 

Wounds  of  abdomen,  non -perforating  i 
perforating      . .          .  .          . .  4 

—  head           . .          . .          . .          . .  210 

—  heart           . .          .  .          .  .           .  .  231 

—  inferior  vena  cava          . .          .  .  238 

—  joints         .  .          .  .          . .          . .  251 

—  knee           . .          . .          . .          . .  264 

—  mahgnant  cedema  due  to          . .  379 

—  pericarditis  from              .  .          .  .  390 

—  of  spine     . .          .  .          . .          .  .  479 

—  thoracic  duct        ..          ..          ..  513 

—  treatment  to  prevent  tetanus  . .  512 
Wrist,   fracture   of  bones  of        186,  191 

—  sprained     .  .          .  .          .  .          . .  249 

—  tuberculosis  of      . .          . .          . .  88 

Wjmter-Handley  operation  for  ascites  279 

"V-RAY  burns          ..          ..          ..  121 

■^  X  rays  in  cancer  of  uterus  . .  529 
vulva    . .          . .          . .          . .  542 

—  chronic  anterior  poliomyelitis  . .  348 

—  fibroids  of  uterus. .          . .          . .  534 

—  harmful    in    splenic    anaemia    of 

infancy            . .          . .          •  •  19 

—  influence  in  prognosis  of  breast 

cancer  . .          . .          . .          . .  114 

—  in  injuries  of  knee-joint  . .          . .  262 

—  leukaemia   .  .          . .          .  .        272,  273 

—  lichen  planus        . .          . .          . .  274 

—  lupus     erythematosus,     epitheli- 

oma following         .  .          . .  282 
vulgaris,  dangers  of  . .          . .  283 

—  lymphadenoma     .  .          .  .         286,  287 

—  mycosis   fungoides            .  .          - .  349 

—  ovarian  tumours  . .          . .          ■ .  383 

—  psoriasis     . .          . .          .  •          -  •  4^4 

—  recurrent  cancer  of  breast        . .  113 

—  renal  calculi          ■  ■          ■  ■          ■  •  258 

—  and  ringworm       .  .          ■  •           •  ■  461 

—  in  rodent  ulcer     .  .          .  .          .  .  462 

—  splenic  anaemia     . .          •  .          •  •  i7 

—  value  of  secondarj'        . .         113,  114 

YELLOW  FEVER  ..  -.544 

-'■      Young's    bar-punch    operation 

in  enlarged  prostate           - .  412 


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